Case and Research Letters
Reactivation of Skin Lesions After Patch Testing to Investigate Drug Rash With Eosinophilia and Systemic Symptoms (DRESS) Syndrome
Reactivación de las lesiones cutáneas por pruebas epicutáneas en el estudio de un síndrome de DRESS
S. Córdoba
, B. Navarro-Vidal, C. Martínez-Morán, J. Borbujo
Corresponding author
Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain
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Córdoba, B. Navarro-Vidal, C. Martínez-Morán, J. Borbujo" "autores" => array:4 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Córdoba" "email" => array:1 [ 0 => "susana.cordoba@salud.madrid.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "B." "apellidos" => "Navarro-Vidal" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Martínez-Morán" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "Borbujo" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Reactivación de las lesiones cutáneas por pruebas epicutáneas en el estudio de un síndrome de DRESS" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1125 "Ancho" => 750 "Tamanyo" => 165961 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesions of lesser intensity similar to those of the previous rash. Reactivation after patch tests.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, also known as drug-induced hypersensitivity syndrome, is an uncommon severe reaction with a late onset and prolonged course that is sometimes fatal (10%-40%). The pathogenesis of this condition is complex, and various factors are believed to interact, including accumulation of drug metabolites, HLA-associated predisposition, drug-virus interactions, alternating cycles of immunosuppression and immune recovery, and the presence of drug-specific T lymphocytes.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> DRESS syndrome is a type IV hypersensitivity reaction that is mediated by type 2 helper T cells.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We report the case of a 24-year-old man who attended the emergency department with a 2 to 3–day history of generalized erythematous maculopapular rash (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>), fever >39<span class="elsevierStyleHsp" style=""></span>°C, and painful enlarged lymph nodes (>2<span class="elsevierStyleHsp" style=""></span>cm) on both sides of his neck. The mucosa was not involved. The patient had a personal history of asthma, anxiety, and chronic prostatitis and had been receiving montelukast, inhaled salmeterol/fluticasone, and bromazepam for more than a year. In addition to his usual treatment, he had received trimethoprim-sulfamethoxazole during the previous month. The blood workup revealed leukocytosis of up to 21 300<span class="elsevierStyleHsp" style=""></span>cells/μL with 25% eosinophils and acute hepatitis (aspartate aminotransferase, 91<span class="elsevierStyleHsp" style=""></span>U/L; alanine aminotransferase, 599<span class="elsevierStyleHsp" style=""></span>U/L; and γ-glutamyl transpeptidase, 248<span class="elsevierStyleHsp" style=""></span>U/L); the remaining values were within the normal range. The results of serology testing for hepatotropic viruses were negative. Abdominal ultrasound examination revealed moderate splenomegaly. Chest x-ray and electrocardiogram findings were normal. The skin biopsy revealed spongiosis, lymphatic exocytosis, and necrotic keratinocytes in the epidermis, together with a perivascular mononuclear infiltrate in the dermis. The patient was diagnosed with DRESS syndrome, his previous treatment was stopped, and he was prescribed oral prednisone. Given the persistence of the cutaneous lesions and altered laboratory values despite systemic therapy with corticosteroids, treatment with oral ciclosporin was prescribed for 4 months, until symptoms resolved completely. One month after treatment was suspended, the patient underwent patch testing with the standard series of the Spanish Contact Dermatitis and Skin Allergy Research Group, trimethoprim 2% in dimethyl sulfoxide, and sulfamethoxazole 2% in petrolatum. The results were positive for methylchloroisothiazolinone/methylisothiazolinone (no relevance); the results for the remaining allergens were negative at 48 and 96<span class="elsevierStyleHsp" style=""></span>hours and at 7 days. On the eighth day after the patch tests, the patient developed a generalized maculopapular rash on the trunk that was clinically and histologically similar to the previous rash, although less intense (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>). The rash was interpreted as a reactivation of the rash induced by the patch tests. The lesions resolved completely with oral prednisone. The patient was advised to avoid trimethoprim-sulfamethoxazole and has remained asymptomatic.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Patch testing is considered a useful diagnostic tool in the study of adverse drug reactions,<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> especially those caused by type IV hypersensitivity mechanisms. Although positive results are observed with greater frequency in drug-induced maculopapular rash, generalized exanthematic pustulosis, and fixed drug eruptions, patch testing has also been used in the assessment of other types of reaction, even in more severe reactions.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> The technique is simple and relatively harmless for the patient. The risk of triggering a severe reaction with patch tests is low compared with the risk of a reaction with intradermal testing. Although reactivation of cutaneous lesions can occur, it is considered an uncommon finding.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">3–5</span></a> Patch testing after evaluation of the risk-benefit ratio is even recommended in severe drug hypersensitivity reactions, including DRESS syndrome, toxic epidermal necrolysis, and Steven-Johnson syndrome.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The sensitivity of patch testing in the assessment of DRESS syndrome varies depending on the culprit drug and is greater with anticonvulsant agents, especially carbamazepine. In the case of other drugs involved in the syndrome, the sensitivity of patch testing is considered low.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">2,6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Despite its limited sensitivity, patch testing is an appropriate way of assessing drug-induced reactions before performing prick tests, intradermal tests, and even drug challenge tests, which carry greater risks for the patient.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We present a case of DRESS syndrome caused by trimethoprim-sulfamethoxazole. The patient developed a reactivation of the skin lesions induced by patch tests. The low concentration of drug in the patches, the poor availability of tests, or the fact that the reaction was triggered by a metabolite and not by the drug itself could explain the negative result in the patch tests. Nevertheless, percutaneous absorption from the patches was sufficient to cause a generalized reaction.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Córdoba S, Navarro-Vidal B, Martínez-Morán C, Borbujo J. Reactivación de las lesiones cutáneas por pruebas epicutáneas en el estudio de un síndrome de DRESS. Actas Dermosifiliogr. 2016;107:781–783.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1125 "Ancho" => 750 "Tamanyo" => 201407 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erythematous maculopapular rash on the trunk.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1032 "Ancho" => 750 "Tamanyo" => 164955 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Purpuric erythematous maculopapular lesions on the lower limbs.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1125 "Ancho" => 750 "Tamanyo" => 165961 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Lesions of lesser intensity similar to those of the previous rash. Reactivation after patch tests.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Novedades en el diagnóstico de las toxicodermias" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. De la Torre" 1 => "H.J. 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Kara" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1440-0960.2012.00887.x" "Revista" => array:6 [ "tituloSerie" => "Australas J Dermatol" "fecha" => "2012" "volumen" => "53" "paginaInicial" => "274" "paginaFinal" => "277" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22524313" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/15782190/0000010700000009/v1_201611010039/S1578219016302189/v1_201611010039/en/main.assets" "Apartado" => array:4 [ "identificador" => "6157" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Case and Research Letters" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/15782190/0000010700000009/v1_201611010039/S1578219016302189/v1_201611010039/en/main.pdf?idApp=UINPBA000044&text.app=https://actasdermo.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1578219016302189?idApp=UINPBA000044" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 7 | 11 | 18 |
| 2024 October | 68 | 41 | 109 |
| 2024 September | 73 | 19 | 92 |
| 2024 August | 83 | 77 | 160 |
| 2024 July | 96 | 41 | 137 |
| 2024 June | 106 | 36 | 142 |
| 2024 May | 69 | 37 | 106 |
| 2024 April | 93 | 34 | 127 |
| 2024 March | 79 | 35 | 114 |
| 2024 February | 60 | 27 | 87 |
| 2024 January | 47 | 34 | 81 |
| 2023 December | 70 | 18 | 88 |
| 2023 November | 86 | 27 | 113 |
| 2023 October | 70 | 15 | 85 |
| 2023 September | 63 | 28 | 91 |
| 2023 August | 63 | 13 | 76 |
| 2023 July | 70 | 30 | 100 |
| 2023 June | 53 | 16 | 69 |
| 2023 May | 78 | 27 | 105 |
| 2023 April | 45 | 23 | 68 |
| 2023 March | 49 | 21 | 70 |
| 2023 February | 57 | 27 | 84 |
| 2023 January | 61 | 31 | 92 |
| 2022 December | 61 | 42 | 103 |
| 2022 November | 20 | 21 | 41 |
| 2022 October | 20 | 19 | 39 |
| 2022 September | 24 | 32 | 56 |
| 2022 August | 34 | 32 | 66 |
| 2022 July | 24 | 25 | 49 |
| 2022 June | 24 | 21 | 45 |
| 2022 May | 58 | 51 | 109 |
| 2022 April | 44 | 67 | 111 |
| 2022 March | 67 | 39 | 106 |
| 2022 February | 91 | 22 | 113 |
| 2022 January | 73 | 53 | 126 |
| 2021 December | 60 | 39 | 99 |
| 2021 November | 58 | 47 | 105 |
| 2021 October | 64 | 64 | 128 |
| 2021 September | 47 | 50 | 97 |
| 2021 August | 73 | 34 | 107 |
| 2021 July | 49 | 42 | 91 |
| 2021 June | 106 | 20 | 126 |
| 2021 May | 60 | 47 | 107 |
| 2021 April | 122 | 79 | 201 |
| 2021 March | 104 | 20 | 124 |
| 2021 February | 68 | 27 | 95 |
| 2021 January | 38 | 21 | 59 |
| 2020 December | 51 | 23 | 74 |
| 2020 November | 23 | 11 | 34 |
| 2020 October | 33 | 17 | 50 |
| 2020 September | 41 | 13 | 54 |
| 2020 August | 24 | 20 | 44 |
| 2020 July | 25 | 17 | 42 |
| 2020 June | 32 | 33 | 65 |
| 2020 May | 10 | 9 | 19 |
| 2020 April | 27 | 12 | 39 |
| 2020 March | 31 | 16 | 47 |
| 2020 February | 4 | 0 | 4 |
| 2020 January | 4 | 0 | 4 |
| 2019 December | 6 | 0 | 6 |
| 2019 November | 6 | 0 | 6 |
| 2019 September | 8 | 0 | 8 |
| 2019 August | 4 | 0 | 4 |
| 2019 July | 4 | 0 | 4 |
| 2019 June | 6 | 0 | 6 |
| 2019 May | 4 | 1 | 5 |
| 2019 April | 2 | 5 | 7 |
| 2019 March | 2 | 0 | 2 |
| 2019 February | 5 | 0 | 5 |
| 2019 January | 1 | 0 | 1 |
| 2018 December | 4 | 0 | 4 |
| 2018 November | 9 | 0 | 9 |
| 2018 October | 4 | 0 | 4 |
| 2018 September | 3 | 0 | 3 |
| 2018 August | 1 | 0 | 1 |
| 2018 February | 39 | 5 | 44 |
| 2018 January | 45 | 6 | 51 |
| 2017 December | 61 | 15 | 76 |
| 2017 November | 62 | 10 | 72 |
| 2017 October | 45 | 9 | 54 |
| 2017 September | 37 | 9 | 46 |
| 2017 August | 23 | 4 | 27 |
| 2017 July | 29 | 8 | 37 |
| 2017 June | 41 | 14 | 55 |
| 2017 May | 35 | 3 | 38 |
| 2017 April | 34 | 10 | 44 |
| 2017 March | 24 | 12 | 36 |
| 2017 February | 27 | 7 | 34 |
| 2017 January | 13 | 15 | 28 |
| 2016 December | 28 | 27 | 55 |
| 2016 November | 65 | 48 | 113 |
| 2016 October | 7 | 14 | 21 |
Show all
