Diagnostic criteria for drug rash and eosinophilia with systemic symptoms.

Dear Editor,

We found the paper by Jmeian et al. concerning a case of allopurinol-related drug rash with eosinophilia and systemic symptoms (DRESS) in a patient of chronic kidney disease and gout, interesting.[1] The presence of eosinophilia, the temporal relationship of the symptoms with the initiation of treatment with allopurinol, and the marked improvement on withdrawal of the drug along with the administration of systemic corticosteroids were features suggesting the diagnosis of DRESS.

DRESS is considered a severe drug reaction with a case fatality rate of 10–20%.[2] The diagnosis is sometimes difficult since the clinical manifestations may be incomplete or nonspecific, and it can also present as a purely systemic disease without any cutaneous involvement.[34]

Multiple diagnostic criteria have been developed and used to standardize the diagnosis and management of DRESS, albeit with limited success.

Bocquet et al. were the first who proposed criteria for DRESS [Table 1].[5] The Registry of Severe Cutaneous Adverse Reaction (RegiSCAR) group suggested criteria for hospitalized patients with a drug rash to diagnose DRESS syndrome [Table 2].[6] RegiSCAR constitutes a European RegiSCAR, including Stevens–Johnson syndrome, toxic epidermal necrolysis, acute generalized exanthematous pustulosis, and DRESS. In an effort to define more accurately the DRESS syndrome, a scoring system has also been developed the RegiSCAR scoring system [Table 3].[6] A Japanese group suggested another set of diagnostic criteria; however, universal adaptation of this criteria may be limited since one of the criteria includes HHV-6 activation and some tests, such as measurement of IgG titer anti-HHV 6, are yet not routinely available [Table 4].[7]

Table 1

Bocquet et al. proposed criteria for diagnosis of drug rash and eosinophilia with systemic symptoms/drug-induced hypersensitivity

Table 2

Registry of severe cutaneous adverse reaction criteria for diagnosis of drug rash and eosinophilia with systemic symptoms

Table 3

Registry of severe cutaneous adverse reaction diagnosis score for drug rash and eosinophilia with systemic symptoms

Table 4

Japanese group's criteria for diagnosis of drug rash and eosinophilia with systemic symptoms/drug-induced hypersensitivity

DRESS is a challenging drug adverse reaction which can cause life-threatening organ dysfunction. Clinicians must be alert to this possibility to reach the correct diagnosis and institute the appropriate management.

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