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
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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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| año/Mes | Html | Total | |
|---|---|---|---|
| 2024 Noviembre | 6 | 11 | 17 |
| 2024 Octubre | 68 | 41 | 109 |
| 2024 Septiembre | 73 | 19 | 92 |
| 2024 Agosto | 83 | 77 | 160 |
| 2024 Julio | 96 | 41 | 137 |
| 2024 Junio | 106 | 36 | 142 |
| 2024 Mayo | 69 | 37 | 106 |
| 2024 Abril | 93 | 34 | 127 |
| 2024 Marzo | 79 | 35 | 114 |
| 2024 Febrero | 60 | 27 | 87 |
| 2024 Enero | 47 | 34 | 81 |
| 2023 Diciembre | 70 | 18 | 88 |
| 2023 Noviembre | 86 | 27 | 113 |
| 2023 Octubre | 70 | 15 | 85 |
| 2023 Septiembre | 63 | 28 | 91 |
| 2023 Agosto | 63 | 13 | 76 |
| 2023 Julio | 70 | 30 | 100 |
| 2023 Junio | 53 | 16 | 69 |
| 2023 Mayo | 78 | 27 | 105 |
| 2023 Abril | 45 | 23 | 68 |
| 2023 Marzo | 49 | 21 | 70 |
| 2023 Febrero | 57 | 27 | 84 |
| 2023 Enero | 61 | 31 | 92 |
| 2022 Diciembre | 61 | 42 | 103 |
| 2022 Noviembre | 20 | 21 | 41 |
| 2022 Octubre | 20 | 19 | 39 |
| 2022 Septiembre | 24 | 32 | 56 |
| 2022 Agosto | 34 | 32 | 66 |
| 2022 Julio | 24 | 25 | 49 |
| 2022 Junio | 24 | 21 | 45 |
| 2022 Mayo | 58 | 51 | 109 |
| 2022 Abril | 44 | 67 | 111 |
| 2022 Marzo | 67 | 39 | 106 |
| 2022 Febrero | 91 | 22 | 113 |
| 2022 Enero | 73 | 53 | 126 |
| 2021 Diciembre | 60 | 39 | 99 |
| 2021 Noviembre | 58 | 47 | 105 |
| 2021 Octubre | 64 | 64 | 128 |
| 2021 Septiembre | 47 | 50 | 97 |
| 2021 Agosto | 73 | 34 | 107 |
| 2021 Julio | 49 | 42 | 91 |
| 2021 Junio | 106 | 20 | 126 |
| 2021 Mayo | 60 | 47 | 107 |
| 2021 Abril | 122 | 79 | 201 |
| 2021 Marzo | 104 | 20 | 124 |
| 2021 Febrero | 68 | 27 | 95 |
| 2021 Enero | 38 | 21 | 59 |
| 2020 Diciembre | 51 | 23 | 74 |
| 2020 Noviembre | 23 | 11 | 34 |
| 2020 Octubre | 33 | 17 | 50 |
| 2020 Septiembre | 41 | 13 | 54 |
| 2020 Agosto | 24 | 20 | 44 |
| 2020 Julio | 25 | 17 | 42 |
| 2020 Junio | 32 | 33 | 65 |
| 2020 Mayo | 10 | 9 | 19 |
| 2020 Abril | 27 | 12 | 39 |
| 2020 Marzo | 31 | 16 | 47 |
| 2020 Febrero | 4 | 0 | 4 |
| 2020 Enero | 4 | 0 | 4 |
| 2019 Diciembre | 6 | 0 | 6 |
| 2019 Noviembre | 6 | 0 | 6 |
| 2019 Septiembre | 8 | 0 | 8 |
| 2019 Agosto | 4 | 0 | 4 |
| 2019 Julio | 4 | 0 | 4 |
| 2019 Junio | 6 | 0 | 6 |
| 2019 Mayo | 4 | 1 | 5 |
| 2019 Abril | 2 | 5 | 7 |
| 2019 Marzo | 2 | 0 | 2 |
| 2019 Febrero | 5 | 0 | 5 |
| 2019 Enero | 1 | 0 | 1 |
| 2018 Diciembre | 4 | 0 | 4 |
| 2018 Noviembre | 9 | 0 | 9 |
| 2018 Octubre | 4 | 0 | 4 |
| 2018 Septiembre | 3 | 0 | 3 |
| 2018 Agosto | 1 | 0 | 1 |
| 2018 Febrero | 39 | 5 | 44 |
| 2018 Enero | 45 | 6 | 51 |
| 2017 Diciembre | 61 | 15 | 76 |
| 2017 Noviembre | 62 | 10 | 72 |
| 2017 Octubre | 45 | 9 | 54 |
| 2017 Septiembre | 37 | 9 | 46 |
| 2017 Agosto | 23 | 4 | 27 |
| 2017 Julio | 29 | 8 | 37 |
| 2017 Junio | 41 | 14 | 55 |
| 2017 Mayo | 35 | 3 | 38 |
| 2017 Abril | 34 | 10 | 44 |
| 2017 Marzo | 24 | 12 | 36 |
| 2017 Febrero | 27 | 7 | 34 |
| 2017 Enero | 13 | 15 | 28 |
| 2016 Diciembre | 28 | 27 | 55 |
| 2016 Noviembre | 65 | 48 | 113 |
| 2016 Octubre | 7 | 14 | 21 |
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