Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a drug reaction commonly related to eosinophilia, from uncertain epidemiology, and without consensus for diagnosis and treatment globally. It presents a great challenge in its management and is characterized by fever, lymphadenopathy, skin rash, and multisystemic involvement. An aggressive and difficult-to-manage clinical case is presented in a 50-year-old man with chronic kidney disease due to diabetes mellitus type 2 and systemic arterial hypertension, who developed an unusual variant similar to DRESS and Stevens-Johnson syndrome (SJS) overlap secondary to allopurinol, with skin manifestations without eosinophilia, but fulfilling clinical and laboratory criteria for DRESS and SJS syndrome.

Drug-induced Eosinophilia and Systemic Symptoms (DRESS), Stevens-Johnson Syndrome (SJS), and Toxic Epidermal Necrolysis (TEN) are rare but life-threatening immune-mediated drug reactions known as Severe Cutaneous Adverse Reactions (SCARs). These severe drug reactions have been associated with many commonly prescribed medications, including sulfonamides, allopurinol, carbamazepine, and several antiepileptic drugs including lamotrigine.1 Although the risk of these adverse events is recognized by many medical providers, the risk may be overlooked when prescribing lamotrigine for mood disorders. Review of the literature and the experience of these cases suggest that the risk of lamotrigine-associated SCARs is increased when starting lamotrigine at high initial doses. Here we present and discuss two cases of SCARs attributed to high-dose lamotrigine prescribed for mood disorders. A third patient also presented with a SCAR related to high-dose lamotrigine prescribed for a mood disorder during this time but was lost to follow-up and was not reachable. All three patients presented to our hospital system from 2019-2020. Due to this clinical experience, we recommend that pharmacists and prescribers alike be alerted of the risk of severe cutaneous drug reactions when lamotrigine is prescribed, particularly at initial doses greater than 25 mg.

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HIV-infected patients have a higher risk of developing cutaneous reactions to drugs than the general population. Severe cutaneous adverse reactions (SCARs) are not uncommon in patients taking antiretroviral therapy (HAART]. To evaluate HLA class I and II allele frequencies in HIV patients on HAART who develop SCARs due to nevirapine (NVP] or efavirenz (EFZ] containing regime and compare this genotype composition with HAART tolerant patients and healthy organ donors. A case-control study for 4 years was conducted with four subsets of patients hailing from north-east India:Cohort 1- HIV seropositive patients who developed SCARs due to EFZ (n = 8];Cohort 2 - HIV seropositive patients who developed SCARs due to NVP (n = 15]; Cohort 3 -HIV seropositive NVP/EFZ-tolerant patients (n = 18]; Cohort 4 - Healthy HIV seronegative organ donors (n = 169].Cohort 3 & 4 acted as control-group. These patients were genotyped for the HLA-A, HLA-B, HLA-C, HLA-DRB1, HLA-DQB1, and HLA-DPB1 by a sequence-based HLA typing method. HLA-DRB1*03:01 allele revealed a significant association with EFZ regimen-induced SCARs in 62.5% patients compared with only 5.56% observed in HAART-tolerant patients and 4.14% in healthy organ. HLA-B*3505was found to be significantly associated with NVP induced SCARs. We found significant novel association of HLA-DRB1*03:01 with EFZ induced SCARs in North-East Indian HIV patients. Thus, HLA-DRB*03:01 may be useful as a genetic marker to avoid EFZ induced serious cutaneous rashes. The molecular HLA characterization of these alleles may provide a novel insight into the immunological basis of the antiretroviral drug reactions.

We describe a case of a 33-year-old-male with Mycoplasma pneumoniae-induced rash and mucositis and review the literature on this newly described syndrome.

We describe the case of a 49-year-old, otherwise healthy, Hispanic male who underwent an uncomplicated vasectomy and was treated prophylactically with a one-week course of ciprofloxacin. Two days after completing the antibiotic course, he developed a pruritic, blistering rash that covered 90% of his body surface area. Punch biopsy of the skin lesions confirmed the diagnosis of Stevens-Johnson syndrome (SJS). Upon further questioning, it was revealed that the patient had consumed approximately 32 ounces of grapefruit juice each of the seven days following his vasectomy. We hypothesized that the cytochrome P450 inhibitory effect of grapefruit juice had dramatically elevated systemic levels of ciprofloxacin, increasing the risk of developing SJS. Literature review revealed that ciprofloxacin is metabolized primarily by CYP1A2 with partial CYP3A4 metabolism, while grapefruit juice is strictly an enterocyte CYP3A4 inhibitor. To the authors\' knowledge, consumption of grapefruit juice has never been demonstrated to increase systemic levels of ciprofloxacin or of other fluoroquinolones. We conclude that either this is the first reported case of a grapefruit juice-ciprofloxacin interaction causing SJS, or that this is simply ciprofloxacin-induced SJS. Importantly, ciprofloxacin is not recommended by the American Urological Association for a routine vasectomy without risk factors for infection. We remind clinicians that inappropriately prescribed antibiotic prophylaxis for routine procedures can cause serious morbidity, including SJS, and should only be prescribed when indicated.