Success with DRESS: What You Need to Know about Drug Reaction with Eosinophilia and Systemic Symptoms

Introduction

Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) is a potentially life-threatening medical emergency. Patients present with fever, rash and internal organ dysfunction or failure. Organs affected include liver (hepatitis, fulminant hepatic failure), lungs (pneumonitis), kidneys (renal failure, nephritis), brain (encephalopathy and/or aseptic meningitis), and heart (myocarditis, heart failure). Endocrine dysfunction such as hyperthyroidism, diabetes mellitus, and SIADH are also sometimes seen. Symptoms usually begin within two to six weeks of starting an offending drug.

Causes

Although more than 200 different medications have been implicated, you only need to remember the small handful of offenders which account for the vast majority of case:

• Anticonvulsants (especially phenobarbital, lamotrigine, and phenytoin)
• Long acting sulfonamides (sulfamethoxazole, sulfadiazine, sulfasalazine, but not sulfonylureas, thiazides, furosemide or acetazolamide)
• Non-Steroidal Anti-Inflammatory Drugs (NSAIDS)
• Allopurinol
• Vancomycin
• Dapsone
• Minocycline
• Nevirapine
• Abacavir

It’s actually not all that hard to memorize this list if you recall that most of these medications are already known to be “bad” for one strange reason or another:

• Phenytoin: gingival hyperplasia, hirsutism, acne, and coarsening of facial features
• Vancomycin: Red Person Syndrome
• Dapsone: methemoglobinemia, hemolytic anemia in patients with glucose-6-phosphate dehydrogenase deficiency (G6PD)
• Minocycline: blue-grey skin discoloration
• Lamotrigine, abacavir, nevirapine: Stevens-Johnson syndrome
• NSAIDS and sulfonamides: both drug classes with lots and lots of side effects!

Allopurinol is the only commonly-used medication on the list which is not otherwise well known for doing lots of nasty things. That is why you should count on precisely this drug to trip you up on the Boards. (After all, anyone can pick sulfonamides or NSAIDS out of a lineup!)

Treatment

Treatment is with corticosteroids and with cessation of offenders.

Before starting corticosteroids, however, consider sepsis as an alternative diagnosis. DRESS is distinguished from sepsis by the presence of eosinophilia and rash.

References