Drug reaction with eosinophilia and systemic symptoms & acute generalized exanthematous pustulosis 2019 Presented by Nattasasi Suchamalawong, MD. November 15, 2019

1. Drug Reaction with Eosinophilia and Systemic Symptoms
&
acute generalized exanthematous pustulosis
15TH NOVEMBER 2019
NATTASASI SUCHAMALAWONG ,MD
PEDIATRIC ALLERGY AND IMMUNOLOGY UNIT
KING CHULALONGKORN MEMORIAL HOSPITAL

2. Severe cutaneous adverse reactions (SCARs)
SJS/TEN
DRESS syndrome
AGEP

3. Naranjo’s algorhythm
Mazhar F. et al, J of Research in Pharmacy Practice, Oct-Dec 2016.
Doubtful < 0
Possible 1-4
Probable 5-8
Definite > 8

4. Mortality
:
SJS : 10%
TEN : > 30%
DRESS : 10%
AGEP : 2%

5. Drug Reaction with Eosinophilia
and Systemic Symptoms
(DRESS syndrome)

6. Overview
• Historical Background
• Etiology
• Pathogenesis
• Clinical features
• Histopathologic finding
• Diagnosis criteria
• Differential diagnosis
• Clinical testing
• Treatment
• Prognosis

7. Historical Background
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18,
phenytoin first became
available observed in patients
treated with anticonvulsants.
Dilantin Hypersensitivity : reported a case of
fever, hepatitis, and exfoliative dermatitis
by Chaiken et al .
Proposed the term DRESS by Bocquet et al .
DRESS associated viral reactivation
( human herpesvirus -6)
1930 1950 1996 1997

8. Drug-induced pseudolymphoma and drug hypersensitivity syndrome
(Drug Rash with Eosinophilia and Systemic Symptoms: DRESS).
Bocquet H1, Bagot M, Roujeau JC.Department of Dermatology, Hopital Henri Mondor, Université Paris XII, France.
Semin Cutan Med Surg. 1996 Dec;15(4):250-7.
DRESS term includes two different patterns:
(1) hypersensitivity syndrome :
acutely in the first 2 months after the initiation of the drug
fever, severe skin disease with infiltrated papules and facial edema or an exfoliative dermatitis,
lymphadenopathy, hematologic abnormalities (hypereosinophilia, atypical lymphocytes) and
organ involvement - hepatitis, carditis, interstitial nephritis, or interstitial pneumonitis.
Histological pattern shows a lymphocytic infiltrate
(2) drug-induced pseudolymphoma
insidious beginning with nodules and infiltrated plaques appearing several weeks after the beginning of
the drug without constitutional symptoms.
Complete improvement is usual after drug withdrawal, but a delayed lymphoma is possible.

9. Drug-induced pseudolymphoma and drug hypersensitivity syndrome
(Drug Rash with Eosinophilia and Systemic Symptoms: DRESS).
Bocquet H1, Bagot M, Roujeau JC.Department of Dermatology, Hopital Henri Mondor, Université Paris XII, France.
Semin Cutan Med Surg. 1996 Dec;15(4):250-7.
Proposed criteria of a diagnosis for drug rash with DRESS(Bocquet et al)
▪ Cutaneous drug eruption
▪ Hematologic abnormalities
Eosinophilia > 1500/dl or
Presence of atypical lymphocytes
▪ Systemic involvement
Adenopathy > 2 cm in a diameter
Hepatitis (transaminases > 2N)
Interstitial pneumonitis
Interstitial nephritis
Carditis

10. Prevalence
▪ Prevalence was 10 cases per 1,000,000 inpatients.
▪ Median age 51.4 year in men , 55.7 years in women .
▪ Female predominated , elderly black skin
▪No increase incidence of personal and family history atopy and drug eruption
T. Shiohara, Y. Mizukawa / Allergology International 68 (2019) 301-308

11. Prevalence
▪ Prevalence was 9.63 cases per 100,000 inpatients.
▪ Median onset time (IQR) was 16 (9-27) days.
▪ Female > male
▪ Most common causative agents were phenytoin (23.1%), nevirapine
(17.3%), allopurinol (15.4%), and cotrimoxazole (13.5%).
Allergology International Volume 65, Issue 4, October 2016, Pages 432-438

12. Etiology
• severe hypersensitivity to a medication and its reactive drug
metabolites , which may be associated with enzymatic defects in
drug metabolism
• Immunosuppression especially when accompanied by a primary or
reactivation human herpesvirus-6 (HHV-6) infection
Zain Husain, MD,a Bobby Y. Reddy, MD,b and Robert A.
Schwartz, MD , J Am Acad Dermatol 2013;68:693.e1-14.

13. Common drugs causing DRESS syndrome
American Journal of Clinical Dermatology (2019) 20:217–236

14. แนวทางการดูแลรักษากลุ่มอาการ Drug hypersensitivity syndrome
(Clinical practice guideline in the diagnosis and
management of drug hypersensitivity syndrome),2016
Common drugs
causing DRESS
syndrome in Thailand

15. A total of 52 patients
common causative agents were phenytoin (23.1%),
nevirapine (17.3%), allopurinol (15.4%), and cotrimoxazole (13.5%).
prevalence was 9.63 cases per 100,000 inpatients.
Clinical : skin rash 100%, fever 78.8%, and lymphadenopathy 50%.
The most common internal organ involvement was liver (94.2%).
A half of patients received systemic corticosteroids.
2 mortality cases were reported (omeprazole-fulminant hepatitis
and phenytoin-nosocomial infection).
Allergology International Volume 65, Issue 4, October 2016, Pages 432-438

16. Conclusion
DRESS is associated with severe morbidity and mortality.
Phenytoin, nevirapine, allopurinol, and cotrimoxazole were the major causes. Allopurinol-
induced DRESS had the longest onset time, and was associated with higher eosinophilia and
incidence of renal involvement. Raising awareness among both health care providers and
public for early detection and withdrawal of the causative agent is critical to save life and
reduce morbidity.
Allergology International Volume 65, Issue 4, October 2016, Pages 432-438

17. Pathogenesis
• Genetic Factors
• Viral reactivation
Journal of Allergy and Clinical Immunology 2015 136, 219-234
Models of T – cell activation by small molecules antigen

18. Pathogenesis
• Genetic Factors
• Viral reactivation
Models of T – cell activation by small molecules antigen
Int Arch Allergy Immunol 2016;170:163–179

19. Genetic Factors
• Gene encoding metabolizing enzyme for drugs : Failure to detoxification, accumulation of
toxic metabolites
- cytochrome P (CYP) 450 enzyme
- N-acetyltransferase
- CYP2C9*3
• Gene encoding HLA molecules : Drug-specific T-cells, HLA predisposition
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18, 1243

20. Associations between HLA alleles and DRESS syndrome
American Journal of Clinical Dermatology (2019) 20:217–236

21. White et al.Journal of Allergy and Clinical Immunology august 2015

22. White et al.Journal of Allergy and Clinical Immunology august 2015

23. Int Arch Allergy Immunol 2016;170:163–179

24. Int Arch Allergy Immunol 2016;170:163–179

25. Int Arch Allergy Immunol 2016;170:163–179

26. Pathogenesis
• Genetic Factors
• Viral reactivation
Journal of Allergy and Clinical Immunology 2015 136, 219-234DOI

27. Viral Reactivation
-Direct effect of drugs or metabolites on viral reactivation
-In vitro
- early stage of DRESS syndrome, or DiHS, the number of Treg cells expands, even as
a reduced number of B cells and hypogammaglobulinemia
- pro-inflammatory cytokines and chemokines, such as TNF-α, IFN-γ, IL-1, IL-2, IL-6,
are seen in lower levels in the early stage of the disease in patients with HHV-6
reactivation than in those without HHV-6 reactivation, with the exception of one
chemokine, interferon γ-induced protein (IP)-10
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18,

28. Viral Reactivation
-Intercurrent infection (URI or UTI) in cases of maculopapular eruption in 58 % of cases.
Mechanism
❑Transient drug induced hypogammaglobinemia is susceptible individuals creates an
immunological environment that permits viral reactivation.
❑ Complications of the viral reactivation
1. The sequential reactivation of these virus may be responsible for the delayed onset
,paradoxical worsening of clinical features ,long after discontinuation of drug.
2. Sodium valproate directly induce HHV-6 replication.
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18,

29. Pathophysiology of
DRESS syndrome
Philippe Musette,* and Baptiste Janela.Front. Med., 04 December 2017

30. Pathophysiology of DRESS
Dysfunction in drug metabolism and detoxification
- Slow acetylators
-Related to Epoxide Hydroxylase deficiency Leads to accumulation of toxic metabolite
ARENE OXIDES
Trigger immunological response

31. Pathophysiology of DRESS
❑ Generation of drug specific T-cell recognition Endothelial damage
❑ Reactivation of HHV-6,7; EBV, CMV, Hepatitis C virus
❑ A multiorgan T cell response ( TNF-α ,INF -γ ,IL-2)
❑ Increase in IL-5 Eosinophilia

33. Clinical features
Reaction occur after 2 wks-3 months of therapy.
HHV-6 reactivation : within 2-3 wks of reaction
Symptoms may worsen after drug discontinued.
Symptoms may last weeks to even months after drug discontinued.

34. Clinical features
Skin lesion
Present in 73-100% .
Facial edema found in 76% of patients,
is the hallmark feature of disease
Skin lesions can be :
1. Infiltrated papules(follicular or non – follicular)
2. Generalized papulopustular
3. Exanthematous rash
4. Exfoliative dermatitis

35. JC Chan et al. Hong Kong J Dermatol Venereol. 2012

36. Internal organ involvement
• Both hematological abnormalities and impairment of solid organs.
• Hematological changes , eosinophilia is the most common (66-95%) ,atypical lymphocyte
(27-67%)
• Lymphadenopathy (54%)
• Decreased number of B lymphocytes with
hypoglobulinemia .
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18, 1
Organ % of patient involvement
Liver 80
Kidney 40
Pulmonary 33
Cardiac(myocarditis) 15
Pancreas 5
Hypothyroidism <5
CNS(encephalitis) <5

37. Internal organ involvement
- Liver injury found ( 75-94% of patients):
cholestatic type 44% , mixed type 33% , hepatocellular type 23%
- Renal involvement (12-40%) :allopurinol.
- Lung involvement : interstitial pneumonitis , pleuritis, acute respiratory distress
-Cardiac involvement ( 4-27% ) :hypersensitivity myocarditis,
acute necrotizing eosinophilic myocarditis .
-Neurologic involvement ( menigitis , encephalitis )
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18, 1

38. Drugs associated with specific internal organ involvement risk in
drug reaction with eosinophilia and systemic symptoms syndrome
Indian J Dermatol. 2018 Jan-Feb; 63(1): 30–40.

39. Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18, 1243

40. Diagnostic protocol of drug reaction with eosinophilia and systemic symptoms
Indian J Dermatol. 2018 Jan-Feb; 63(1): 30–40.

41. Histopathologic finding
Histopathological patterns in skin lesions of DRESS syndrome.
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18, 1243
Keywords
Dyskeratosis, interface dermatitis
Basal vacuolization
Lymphocyte exocytosis , Dermal edema
Superficial perivascular inflammation

42. Histopathologic finding
Histopathological patterns in skin lesions of DRESS syndrome.
Yung-Tsu Cho, Che-Wen Yang and Chia-Yu Chu , Int. J. Mol. Sci. 2017, 18, 1243
1. Dyskeratosis
2. Basal vacuolation
3. Lymphocyte exocytosis
4. Dermal edema
5. Superficial perivascular inflammation

43. Diagnosis criteria

44. Diagnosis criteria
Final score Interpretation
<2 points No case
2-3 points Possible case
4-5 points Probable case
>5 points Definite case
RegiSCAR

45. Investigation : in vivo testing
• Patch testing.
- safe in vivo test used to identify the causative drug of a hypersensitivity syndrome
- PT should be performed on the sites that were previously affected.
- should be performed during the 6 months following DRESS/DiHS and 1 month after
any immunosuppressive treatment
- negative predictive values (NPVs) and positive predictive values (PPVs) are
unknown.
The PPV of patch testing under optimal conditions was as high as 80% to 90% for
certain drugs, American Journal of Clinical Dermatology
April 2019, Volume 20, Issue 2, pp 217–236

46. Investigation : in vivo testing
• Patch testing.
- One study reported that the positive predictive values were higher than the
negative predictive values, and that they were high as 80–90% for certain drugs such
as carbamazepine, but only around 10–20% for other medications such as
phenobarbital.
As a result, a positive patch test is a highly reliable indicator of an
inflammatory cutaneous hypersensitivity reaction, while a negative
test does not exclude it.
American Journal of Clinical Dermatology
April 2019, Volume 20, Issue 2, pp 217–236

47. Investigation : in vitro testing
European Network on Drug Allergy (ENDA) and
European Academy of Allergy and Clinical Immunology (EAACI)
: evaluation for confirmation of culprit drug
(recommendation grade C )
--Lymphocyte transformation test (LTT)
--Drug-specific IFN-γ-releasing cells by
enzyme-linked immunospot (ELISpot)
-- Combined cytokine and cytotoxicity assay
American Journal of Clinical Dermatology .April 2019, Volume 20, Issue 2, pp 217–236

48. in vitro testing : lymphocyte transformation test
LTT (lymphocyte transformation test) :
• Sensitivity in the range of 60% to 73% and specificity of > 85%
• Recommended to perform LTT 4 to 8 weeks after remission in order to elude high
proliferation of spontaneous cells
• limitations of LTT include its cumbersome nature, the need for significant
experience with cellular techniques, expensive equipment, and the reliance upon an
interpreter with a strong background in pharmacology and immunology
LTT : limited sensitivity, a negative LTT cannot exclude drug hypersensitivity
American Journal of Clinical Dermatology .April 2019, Volume 20, Issue 2, pp 217–236

49. in vitro testing :Drug-specific IFN-γ-releasing cells
by enzyme-linked immunospot (ELISpot)
Identification of the culprit drug based on cytokine secretion
•Proposed for used in the acute phase (increase IFN-γ and TNF-α )of the hypersensitivity
when is urgent to determine the culprit drug
• ELISpots did not increase sensitivity compared with LTTs when evaluating patients with
DRESS but markedly increased sensitivity in SJS/TEN from 35% to 71%, with no changes
in specificity (96%)
• Recommended to perform ELISpot 4 to 8 weeks after remission in order to elude high
proliferation of spontaneous cells
Elispot : limited sensitivity, a negative cannot exclude drug hypersensitivity
American Journal of Clinical Dermatology .April 2019, Volume 20, Issue 2, pp 217–236

50. Investigation : in vitro testing
Mayogra ET AL.J ALLERGY CLIN IMMUNOL VOLUME 143, NUMBER 1.2018

51. Prognosis and Long-Term Sequelae
▪ Poor prognosis : HHV-6 reactivation, pancytopenia, hypereosinophilia > 1500 cells/μL,
HR > 90 beats/min, white blood cells > 12,000/mm3, RR > 20 bpm, coagulopathy,
gastrointestinal bleeding, and systemic inflammatory response syndrome
▪Complications include Fulminant myocarditis, Pneumocystis jirovecii pneumonia, sepsis, and
gastrointestinal bleeding , CMV infection
▪Most common cause of mortality : Hepatic dysfunction , fulminant myocarditis
▪Long-term sequelae : end-organ failure or autoimmune diseases such as hyperthyroidism,
hypothyroidism, type 1 diabetes, systemic , lupus erythematosus (SLE), autoimmune
hemolytic anemia, and sclerodermoid graft-versus-host disease-like lesions ,chronic
exfoliative dermatitis (most common), xerosis
Mayogra ET AL.J ALLERGY CLIN IMMUNOL VOLUME 143, NUMBER 1.2018

52. Target
treatment
Asia Pac Allergy. 2019 Jul;9(3):e20

53. The French Society of Dermatology proposed the following
treatment algorithm:
T. Shiohara, Y. Mizukawa / Allergology International 68 (2019) 301-308
(a) absence of severity signs : symptomatically with topical corticosteroid emollients
and H1 antihistamines.
(b) In the presence of signs of severity (transaminases levels > 5 times normal; pneumonia, heart and/or
kidney involvement; and hemophagocytosis ) : systemic corticosteroids equivalent to 1 mg/kg/day of
prednisone with a multidisciplinary approach.
(c) In a life-threatening ( hemophagocytosis with BM failure, encephalitis, severe hepatitis ,renal failure, and
respiratory failure) : systemic corticosteroids are recommended with intravenous immunoglobulin (IVIG) at a
dose of 2 g/kg over 5 days.
(d) presence of severity signs and confirmation of a major viral reactivation (HHV-6) :
systemic corticosteroids plus antiviral medications (e.g., ganciclovir) with or without IVIG is recommended

54. Final score Interpretation
<1 points mild
1-3 points moderate
>3 points severe
T. Shiohara, Y. Mizukawa / Allergology International 68 (2019) 301e308

55. Fig. 3. Proposed flow diagram for diagnosis and prognostication
of DiHS/DRESS based on early and late scores.14
T. Shiohara, Y. Mizukawa / Allergology International 68 (2019) 301e308

56. - should not be given empiric antibiotics or anti-inflammatory drugs during the
acute stages of DRESS syndrome - minimum dose of 1.0 mg/kg/day of prednisone or
equivalent. Gradual taper over 3 to 6 months after clinical and laboratory
stabilization is recommended to avoid relapse - Can be treated with intravenous
methylprednisolone. A course of pulsed methylprednisolone, 30 mg/kg
intravenously for 3 days - Immunosuppression from steroid therapy may promote
the reactivation of viruses, such as HHV-6 or CMV

57. Alternative steroid-sparing therapies
• Nevirapine-induced DRESS syndrome successfully treated with IVIG (1 g/kg for 2 days).
• Did not recommend the use of IVIG monotherapy in the treatment of DRESS
syndrome.
• IVIG is thought to be effective in DRESS syndrome therapy because it replenishes the
low immunoglobulin levels in the patient’s blood, supports immune protection against
HHV-6, and has anti-inflammatory properties
• Plasmapheresis and immunosuppressive drugs, such as cyclophosphamide,
cyclosporine, interferons, muromonab-CD3, mycophenolate mofetil, and rituximab, may
also be potential therapies
J Am Acad Dermatol 2013;68:693.e1-14.

59. Differential diagnosis
1-3 weeks

60. AGEP
acute generalized Exanthematous pustulosis

61. AGEP : T cell mediated reaction
▪Characterized : characterized by numerous, nonfollicular, sterile pustules on an erythematous
and edematous base (gram stain : PMN, no organism), fine pustules, fever (>38 C) and
neutrophilia (ANC > 7,000)
▪Distribution face, limbs, and trunk, with a toward intertriginous areas.
▪90% drug-induced
▪Infections : ParvovirusB19, CMV, Mycoplasma, Chlamydia pneumoniae
▪Onset : within 2 days to 2-3 weeks (ATBs may develop within 24 hrs.)
▪Abrupt onset
J AM ACAD DERMATOL VOLUME 73, NUMBER 5 ,2015

62. Clinical features of AGEP
➢acneiform and morbilliform eruptions starting from intertriginous areas, or face then
spread to trunk and lower limbs.
➢ Burning and itching sensation present.
➢ Multiple small pinhead sized , 5mm non – follicular sterile pustules arise at the site of
the rash.
➢ Mucous membrane is involvement ( 20%) usually mild limited to oral mucosa.
➢ After 2 weeks – generalized desquamation occurs after pustules subside.
Ann Allergy Asthma Immunol 120 (2018) 90–106

63. Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

64. Other Drugs causing AGEP
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

65. Pathogenesis of AGEP
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.
activation and expansion of drug-specific T-cells with
subsequent migration to the skin
Influx of drug-specific cytotoxic T-cells and presentation of the
drug bound to major histocompatibility complex Class I by
keratinocytes result in apoptosis of the keratinocyte from
perforin and granzyme release and the Fas-Fas ligand.
formation of acantholysis
and subcorneal Pustules.

66. Pathogenesis of AGEP
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

67. Castells & Bonamichi-Santos, Clin Immunol 5ed.2019.
Histopathology : Neutrophilic spongiotic pustule
pustules are present within the stratum corneum
and/or the epidermis

68. Differential diagnosis of AGEP
1. Pustular psoriasis
2. Bacterial folliculitis
3. Localized pustular contact dermatitis
4. Dermatophyte infection
5. Pyoderma vegetans
6. Varicella
7. Kaposi’s varicelliform eruption
8. Sweet’s syndrome
9. Bechet’s syndrome
10. Infantile chronic acropustulosis

69. AGEP Pustular psoriasis
History of psoriasis Possible Mostly
Duration pattern Predominant in the folds More generalized
Duration of pustules Shorter Longer
Duration of fever Shorter Longer
Hx drug reaction Usual Uncommon
Recent drug
administration
Very frequent Less frequent
Arthritis Rare 30%
Histology Subcorneal or intraepidermal
pustules,papillary edema,
lymphohistiocytic infiltrate
Subcorneal and /or intraepiderma
pustules,papillomatosis, acanthosis
DDx of acute generalized exanthematous pustulosis

70. DDx of acute generalized exanthematous pustulosis
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

71. Investigation of AGEP
▪ Hematological – Leukocytosis >> Neutrophilic(90%)
Eosinophilia in 30% cases
▪ LFT and renal function can be abnormal.
▪ Patch test : Resolution phase
▪ Lymphocyte transformation tests- suggest involvement of T cells in AGEP.
▪ Re-administration (re-challenge) is not advised.
▪ Skin biopsy
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

72. The EuroSCAR study group
developed a standardized AGEP
validation score
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

73. Patch testing 4-6 wks
after resolution
Sensitivity : AGEP 58% >
SJS/TEN 24%
Indian J Dermatol. 2018 Jan-Feb; 63(1): 22–29.

74. Histopathology of AGEP
Subcorneal or Intraepidermal pustules
Papillary edema
Lymphohistiocytic infiltrate with some neutrophils and eosinophils
Ann Allergy Asthma Immunol 120 (2018) 90–106

75. Management
•Stop the suspected medication.
•Self-limited, pustules resolve within 4-10 days.
•Desquamation resolution
•Supportive treatment : Emolient, topical corticosteroid, antihistamine
•Systemic corticosteroid : rarely indicated

76. Asia Pac Allergy. 2019 Jul;9(3):e20

77. Overlapping Features of Acute Generalized
Exanthematous Pustulosis (AGEP) and
Drug-Related Rash with Eosinophilia and
Systemic Symptoms Syndrome (DRESS)

78. Case report
74 yr old woman with metastatic renal cancer diagnosis Piperacillin/Tazobactam-
Associated Hypersensitivity Syndrome with Overlapping Features of Acute Generalized
Exanthematous Pustulosis and Drug-Related Rash with Eosinophilia and Systemic
Symptoms Syndrome
Annual of Dermatology. 2016
Feb; 28(1): 98–101.

79. Eosinophil
neutrophil
Annual of Dermatology. 2016
Feb; 28(1): 98–101.

80. SCARs with both the DRESS syndrome and AGEP caused by anti-tuberculosis (TB) drugs are
rarely reported. Only two retrospective studies and one case report regarding DRESS with
anti-TB drugs are available .No studies have investigated moxifloxacin-induced AGEP. Here,
we report one case of DRESS syndrome caused by anti-TB drugs that progressed to a serious
hypersensitivity AGEP reaction caused by moxifloxacin administration.
International Journal of Clinical Pharmacology and Therapeutics, Vol. 54 – No. 10/2016 (808-815)

81. rifampin-induced skin rash
Anti-TB induce DRESS
flushing and a burning sensation
erythematous pustules :AGEP
International Journal of Clinical Pharmacology and Therapeutics, Vol. 54 – No. 10/2016 (808-815)

82. Patients with drug allergy and hypersensitivity แนวทางการวินิจฉัยผู้ป่วยแพ้ยา ,พญ. ทิชา ลิ้มสุวรรณ

83. Prognosis
Patients with drug allergy and hypersensitivity แนวทางการวินิจฉัยผู้ป่วยแพ้ยา ,พญ. ทิชา ลิ้มสุวรรณ

84. แนวทางการดูแลรักษากลุ่มอาการ Drug hypersensitivity syndrome (Clinical practice guideline in
the diagnosis and management of drug hypersensitivity syndrome),2016

85. แนวทางการดูแลรักษากลุ่มอาการ Drug hypersensitivity syndrome (Clinical practice guideline in
the diagnosis and management of drug hypersensitivity syndrome),2016
Drug eruption อื่น

86. Thank you for your attention