背景:嗜酸粒细胞增多症和全身症状(DRESS)综合征是一种严重的药物不良反应,其特征是引起皮肤和全身并发症的迟发性超敏反应。由于临床表现和症状与其他疾病重叠的多样性,DRESS诊断具有挑战性。这些患者的围手术期需要精确的药理学策略来预防与该综合征相关的并发症。在体外循环(CPB)手术期间由普通肝素诱导的DRESS的治疗提出了一些挑战,在选择抗凝剂以避免副作用时必须考虑这些挑战。在这种情况下,bivalirudin,一种直接的凝血酶抑制剂,在接受CPB的患者中被指定为肝素的替代品。然而,与肝素/鱼精蛋白相反,没有比伐卢定的直接逆转剂。
方法:我们报告一例11岁男性,诊断为左下肢天然主动脉瓣心内膜炎和血栓形成。在瓣膜置换手术中,全身使用普通肝素.术后,病人出现发热,嗜酸性粒细胞增多和瘙痒性皮疹。随后出现温休克和丙氨酸转氨酶(ALT)和天冬氨酸转氨酶(AST)水平升高,导致DRESS综合征的诊断。甲基强的松龙治疗可完全缓解症状。七年后,由于抗凝治疗不足和人工主动脉瓣血栓,患者再次入院。由于使用普通肝素而出现反复的DRESS发作,后来在住院期间用低分子量肝素代替。开始使用皮质类固醇和抗组胺药治疗,导致了这一集的解决。最终,病人需要Ross手术.在此干预期间,抗凝策略被修改,术中使用比伐卢定代替普通肝素,术后使用磺达肝素.这导致稳定的转氨酶水平和无嗜酸性粒细胞增多。
结论:DRESS综合征的严重程度强调了早期识别的重要性,加强监测,和一个全面的方法,适合每个病人的需求。这个特殊的案例突出了这种方法的重要性,并且可能具有实质性的临床影响,因为它提供了肝素的替代品。如比伐卢定和磺达肝素,在CPB的抗凝策略中,对于对这种药物有过度反应的患者;因此,通过最小化与药物不良反应相关的风险来提高临床结果。
BACKGROUND: Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome is a severe adverse drug reaction marked by delayed hypersensitivity reactions causing skin and systemic complications. DRESS diagnosis is challenging due to the variety of clinical presentations and symptom overlap with other conditions. The perioperative period in these patients requires precise pharmacological strategies to prevent complications associated with this syndrome. The treatment of DRESS induced by unfractionated heparin during cardiopulmonary bypass (CPB) surgery presents some challenges that must be considered when selecting an anticoagulant to avoid side effects. In this
case, bivalirudin, a direct thrombin inhibitor, is indicated as an alternative to heparin in patients undergoing CPB. However, in contrast to heparin/protamine, there is no direct reversal agent for bivalirudin.
METHODS: We report the
case of an 11-year-old male diagnosed with native aortic valve endocarditis and thrombosis in his left lower extremity. During valvular replacement surgery, systemic unfractionated heparin was administered. Postoperatively, the patient developed fever, eosinophilia and pruritic rash. Warm shock and elevated alanine transaminase (ALT) and aspartate transaminase (AST) levels followed, leading to the diagnosis of DRESS syndrome. Treatment with methylprednisolone resulted in complete resolution of symptoms. Seven years later, the patient was readmitted due to insufficient anticoagulation and a thrombus in the prosthetic aortic valve, presenting a recurrent DRESS episode due to the administration of unfractionated heparin, which was later replaced with low-molecular-weight heparin during hospitalization. Treatment with corticosteroids and antihistamines was initiated, resulting in the resolution of this episode. Ultimately, the patient required the Ross procedure. During this intervention the anticoagulation strategy was modified, unfractionated heparin was replaced with bivalirudin during the procedure and fondaparinux was administered during the postoperative period. This resulted in stable transaminases levels and no eosinophilia.
CONCLUSIONS: The severity of DRESS Syndrome underscores the importance of early recognition, heightened monitoring, and a comprehensive approach tailored to each patient\'s needs. This particular
case highlights the significance of this approach and may have a substantial clinical impact since it provides alternatives to heparin, such as bivalirudin and fondaparinux, in the anticoagulation strategy of CPB for patients who have a hypersensibility reaction to this medication; thus, enhancing clinical outcomes by minimizing risks linked to adverse drug reactions.