Drug – induced hypersensitivity syndrome (DIHS), also known as drug rash with eosinophilia and systemic symp toms (DRESS) or drug-induced delayedmultiorgan hypersensitivity syndrome (D IDMOHS), is a triad of fever, rash, and visceral involvement of acute severity. Drug-induced delayedmultiorgan hypersensitivity syndrome (D IDMOHS) is an acute severe adverse drug reaction with a triad of fever, rash, and visceral involvement. The exact incidence of DRESS is unknown (about 1/10,000 for antiepileptic drugs and sulfonamides), with a high mortality rate of up to 10% and a variety of clinical manifestations, which can be easily misdiagnosed.
The common drugs that cause DRESS syndrome are antiepileptic drugs (phenobarbital, carbamazepine, lamotrigine), antibiotics (minocycline, β-lactams, sulfonamides, abacavir, nevirapine), allopurinol, aminophene, salazosulfapyridine, metoclopramide and fluindanedione. In recent years, aspirin, strontium ranelate, atorvastatin, and vancomycin have also been reported to cause DRESS.
Diagnostic criteria
The main diagnostic criteria are the 2006 Japanese Drug Review Panel (JDRP) and the 2007 RegiSCAR diagnostic criteria. Japan Drug Evaluation Panel Diagnostic Criteria (2006)
①Papular rash appearing more than 3 weeks after the use of certain drugs
②Symptoms persist for more than 2 weeks after discontinuation of the drug causing the disease
③Temperature above 38℃
④Liver function impairment (glutamate aminotransferase > 100 U/L)
⑤ With more than one of the following hematological changes:
a. Elevated white blood cells (> 11 × 109 /L)
b. Presence of anomalous lymphocytes (> 5%)
c. Elevated eosinophils (> 1.5 × 109 /L)
(6) Enlarged lymph nodes
(vii) HHV-6 reactivation
Typical D IHS/DRESS: all of the above items are present; atypical DHS: items (1-5) are present, of which item 4 may also show damage to other organs (e.g. kidney damage).
Treatment
Early diagnosis is a key step in treatment and is critical to the patient’s prognosis. The main treatment includes:
Discontinue allergy-causing drugs immediately, hospitalization, and drink more fluids or fluids to promote the excretion of allergy-causing drugs. At the same time in the acute period need to avoid the experimental application of antibiotics or non-steroidal anti-inflammatory drugs, so as to avoid cross-reactivity between drugs to mask the original clinical symptoms or aggravate the original symptoms. Also need to avoid the application of similar drugs.
2.Application of glucocorticoids The starting dose of glucocorticoids can be decided according to the different drugs, the underlying disease and the age of the patient. Usually methylprednisolone 1g/d intravenously; for those with immune deficiency or serious infection, it is recommended to use half dose shock first, i.e. methylprednisolone 0.5g/d intravenously for 3 days, and then change to methylprednisolone 1g/d intravenously for 3 days. Then tapered. There are also commonly used doses of prednisolone (40-60) mg/d, and the dose is adjusted according to clinical performance. The hormone is usually used for several weeks to months. Some reports in the simultaneous application of the immunosuppressant cyclophosphamide will aggravate the disease, so the clinical application of high doses of hormones should be carefully considered when the application of immunosuppressants.
3, intravenous immunoglobulin For cases with immune deficiency or severe infection and not suitable for glucocorticoid shock therapy and glucocorticoid shock therapy is not effective in patients with severe DRESS, it is appropriate to use high-dose immunoglobulin therapy, the general dosage of immunoglobulin (10-20) g/d, that is, ( 0. 2-0. 4) g/ ( kg・d), intravenous drip for 3 days; if the effect is not obvious, If the effect is not obvious, the dose can be increased to (30-40) g/d, i.e. (0. 6-0. 8) g/(kg-d), for 3 days. The combination of glucocorticoid is better than the high-dose shock therapy with immunoglobulin alone.
4.Anti-viral therapy is very important for HHV-6 reactivation, especially for DRESS with cerebrospinal meningitis.