Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe adverse drug reaction caused by certain medications like carbamazepine. It involves a rash, fever, swelling of lymph nodes and organs like the liver, and high eosinophil counts. DRESS is diagnosed based on clinical features and test results showing eosinophilia, atypical lymphocytes, and elevated liver enzymes. Treatment involves promptly stopping the causative drug, supportive care, and sometimes corticosteroids. Complications can include autoimmune diseases or organ failure. Prognosis is generally good if the offending drug is identified and stopped early.

1. rug
eaction
osinophilia
ystamic
ymptoms
Drug reaction with eosinophilia
and systemic symptoms
Done by: Bayan Al-Ghadeer
Group ( 2)
Block 1.2
King Faisal University College
of Medicine

2. Learning Objectives
Adverse drug reaction
Diagnosis
DRESS Overview
Treatment
Etiology and risk factors
Complication
Pathophysiology
Prognosis
Clinical presentation

3. Introduction
to the topic
Adverse drug reaction
How to identify adverse drug reactions
3

4. What is Adverse drug reaction ?
(ADR) is an unwanted or harmful reaction
experienced following the administration
of a drug or combination of drugs under
normal conditions of use, which is suspected
to be related to the drug.
The reaction may be a known side effect of the
drug or it may be new and previously
unrecognized.
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5. How to identify adverse drug reactions ?
The patient may tell you about symptoms they have experienced
since taking a new medicine.
ADR criteria
Abnormal clinical measurements while on drug therapy
(e.g. temperature, pulse, blood pressure, blood glucose, body weight)
Abnormal biochemical or haematological laboratory results
while on drug therapy
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6. Overview
Definition
Which type of hypersensitivity is it based on ?
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7. What is DRESS ?
is a rare, potentially life-threatening, drug-induced severe,
unexpected hypersensitivity reaction that includes skin eruption,
hematologic abnormalities (eosinophilia, atypical lymphocytosis),
lymphadenopathy, and internal organ involvement (liver, kidney,
lung)
Drug hypersensitivity syndrome
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8. Which type of
hypersensitivity
is DRASS ?
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9. Delayed hypersensitivity reactions
Or type IV hypersensitivity reactions.
inflammatory reactions initiated a secondary cellular response
by mononuclear leukocytes .
Lymphocytes (T cells )
monocytes/macrophages
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10. Etiology and
risk factors
Causes
side effects of “ Carbamazepine (Tegretol)”
side effects of “Diazepam”
Who may develops DERSS ?
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11. What could cause DRESS ?
Antiepileptic agents e.g. carbamazepine
drugs associated with DRESS
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12. Carbamazepine
Antiepileptic drug
Common side effects may include:
•
•
•
•
feeling dizzy
drowsy, or unsteady
Nausea
vomiting
• diarrhea
• constipation
• stomach pain
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13. Cont…
Serious side effect such as:
•
•
•
•
•
•
•
•
•
pale skin and skin pain
feeling light-headed
rapid heart rate,
trouble concentrating
Fever
Chills
sore throat
mouth and throat ulcers
easy bruising or bleeding,
•
•
•
•
•
•
•
•
•
severe tingling
numbness
pain and muscle weakness
Confusion
agitation
vision problems
hallucinations
feeling short of breath
swelling of your ankles or feet
• urinating less than usual
• Jaundice
(yellowing of the skin or eyes)
• severe skin reaction
• swelling in face or tongue
• burning in eyes
• a red or purple skin rash
that spreads (especially in
the face or upper body)
and causes blistering
and peeling.
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14. Diazepam
It is often used in stress and anxiety.
Side effects:
• drowsiness, tired feeling
• memory problems
• dizziness, spinning sensation
• feeling restless or irritable
• muscle weakness
• nausea, constipation
• blurred vision, double vision
• mild skin rash, itching
• loss of interest in sex
•
•
•
•
new or worsening seizures
weak or shallow breathing
feeling like you might pass out
muscle twitching, tremor
• drooling or dry mouth, slurred speech
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15. Carbamazepine
Diazepam
If the patient takes diazepam with tegretol
decrease levels of diazepam
by increasing the elimination of diazepam
by liver enzymes.
increase level of carbamazepine
by decreasing the elimination of carbamazepine
by liver enzymes.
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16. Who may develops DRESS ?
Children
adults without sex predilection
*most cases occur in adults
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17. Pathophysiology
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18. Pathophysiology
pathophysiology of DRESS syndrome remains unclear
A defect in the way the liver metabolizes drugs may be responsible.
immunological imbalance
Another theory is that co-infection with the human herpes virus 6 (HHV6)
is important to initiate the syndrome.
Genetic may play a role. Pharmacogenetic studies have found a relation
between certain population and certain antiepileptic in developing DRESS
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19. Clinical
presentation
Signs & symptoms
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20. Signs & symptoms
Symptoms and signs vary from mild to severe depending on
the patient and drug
Start up to 12 weeks or more after initiation of drug
treatment and can occur after a dose increase .
e.g. the onset of carbamazepine’s side effects
considerably long and may be reach more than 6 months !
Symptoms may persist or recur for several weeks after
stopping drug treatment.
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21. Prominent
eosinophilia
Exanthema
Hepatitis
Lymphadenopathy
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22. Facial swelling
Fever
Generalized
edema
Multi-organ
failure
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23. Diagnosis
Investigations ( exclude & prove )
The most useful test
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24. Investigations
CBC with differential and peripheral blood smear
•
eosinophilia >700/microL suggests the diagnosis of DRESS.
•
In some patients, lymphocytosis
• And/or the finding of atypical lymphocytes on
peripheral smear also support the diagnosis
of DRESS.
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25. Cont...
Liver function tests
• Serum alanine aminotransferase (ALT)
greater than twice the upper limit of normal values
• and/or alkaline phosphatase greater than 1.5 times the
upper limit of normal values on at least two different dates indicate
liver involvement.
If Liver function tests were positive
Serology for viral hepatitis
(hepatitis A IgM antibody, hepatitis B surface antigen, hepatitis B core IgM
antibody, hepatitis C viral RNA) may be useful in excluding acute viral
hepatitis .
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26. Cont...
Serum creatinine and urinalysis
A moderate increase in creatinine level, low grade
proteinuria, and abnormal urinary sediment
with occasional eosinophils indicate kidney involvement.
Skin biopsy
The histologic findings of mild spongiosis and
a lymphocytic infiltrate in the superficial dermis,
predominantly perivascular, with eosinophils
and dermal edema, although not specific,
supports the diagnosis of DRESS.
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27. Cont...
Testing for herpes-virus infection
The search for active infection with human herpes-virus testing for
EBV, HHV-6, or HHV-7 is increasingly performed in patients with DRESS, since
viral infection reactivation may be a marker of prolonged course and increased
risk of complications
Imaging studies
In patients presenting with nonspecific symptoms of pulmonary involvement
(eg, cough, tachypnea/dyspnea), chest radiograph or CT scan may provide
evidence of interstitial pneumonitis and/or pleural effusion
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28. Which drug is responsible ?
Patch test
• helps identify which substances
may be causing a reaction in a patient.
• A patch test relies on the principle of
a type IV hypersensitivity reaction.
• Allergic substance will exhibit
inflammation in the skin
• Useful for detecting an ADR with
carbamazepine and other drugs but not all.
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29. Treatment
29

30. How to treat DRESS?
Stopping all doses of suspected medication causing the symptoms
Keeping the symptoms under control
follow up to avoid relapse
Supportive therapy ( replacement of causative medication )
Antihistamine
Corticosteroids
epinephrine if needed
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31. Complication
& Prognosis
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32. Prognosis & complication
Most patients with DRESS recover completely in weeks to months after
stop replace the drug
Autoimmune diseases have been reported in some patients months or
years after the resolution of the drug reaction.
In rare cases, patients developed chronic renal failure and lymphoma.
death
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33. Adverse drug reaction
Adverse drug reaction could be fatal and a special care should
be provide for the patient.
DRESS in detail
If you as a doctor suspect of drug hypersensitivity reaction, it is
important to take a proper medication history with considering
the side effects.
Summary
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35. http://www.dermnetnz.org/reactions/drug-hypersensitivity-syndrome.html
http://www.rxlist.com/tegretol-side-effects-drug-center.htm
http://www.rxlist.com/valium-side-effects-drug-center.htm
http://treato.com/Carbamazepine,Diazepam/?a=s
http://www.uptodate.com/contents/drug-reaction-with-eosinophilia-and-systemicsymptoms-dress
http://dermnetnz.org/reactions/drug-hypersensitivity-syndrome.html
References
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