Drug Hypersensitivity Reactions
Clinical Assessment and Management
- The American Academy of Allergy, Asthma, and Immunology recommends that patients with suspected drug hypersensitivity reactions, such as maculopapular rash with eosinophilia, should be immediately evaluated for DRESS syndrome, with a focus on calculating the RegiSCAR score to stratify severity 1
- The RegiSCAR score assesses features such as fever, lymphadenopathy, eosinophilia, atypical lymphocytes, skin involvement, and organ involvement, with a score of ≥2 indicating possible DRESS syndrome 1
- Patients with simple drug hypersensitivity reactions typically present with widespread erythematous maculopapular rash without systemic involvement, and usually resolve within 1-2 weeks after drug discontinuation 1
- The Journal for ImmunoTherapy of Cancer suggests that patients with severe cutaneous adverse reactions, such as DRESS syndrome, should be treated with systemic corticosteroids, such as prednisone 0.5-1 mg/kg/day, and monitored closely for progression 2
- The Chest journal recommends that patients with ongoing pulmonary issues, such as continuous air leak, should be evaluated for drug-induced pneumonitis, which can complicate the clinical picture and worsen respiratory status 3
- The American College of Allergy, Asthma, and Immunology recommends that patients with DRESS syndrome should be followed up within 48-72 hours to reassess for progression, and that repeat eosinophil count and liver enzymes should be performed in 3-5 days 1
- Skin biopsy can be helpful in differentiating drug hypersensitivity from viral exanthem, but is not required if the clinical diagnosis is clear 1
- Patients with DRESS syndrome require prolonged steroid taper, with potential for relapse if tapered too quickly, and should be monitored for late complications, such as autoimmune sequelae 2
DRESS Syndrome Management and Diagnosis
Differential Diagnosis and Considerations
- Occupational eosinophilic bronchitis is not relevant given no occupational exposures and systemic features, and can be distinguished from DRESS syndrome by the absence of systemic symptoms and the presence of occupational exposures 4, 5
Addressing Complications
- The persistent air leak post-decortication may be related to underlying surgical complications, and should be evaluated in the context of potential drug-induced pneumonitis as a complicating factor, with consideration of DRESS-related pulmonary involvement 4
DRESS Syndrome Management
Diagnosis and Differential Diagnosis
- Eosinophilic granulomatosis with polyangiitis (EGPA) is less likely given acute onset, clear drug exposure, and absence of asthma history, as noted by the European League Against Rheumatism 6, 7