Drug reaction with eosinophilia and systemic symptoms, or virus reactivation with eosinophilia and systemic symptoms as a manifestation of immune reconstitution inflammatory syndrome in a patient with HIV ?

Abstract

We report a case of drug reaction with eosinophilia and systemic symptoms (DRESS) in a patient with HIV receiving antitoxoplasmic drugs (adiazine and pyrimethamine) and levetiracetam along with highly active antiretroviral therapy (tenofovir-emtricitabine, darunavir and ritonavir). Cytomegalovirus (CMV) infection was reactivated in the 7 weeks before the development of DRESS but was successfully treated with ganciclovir and corticosteroids. DRESS flare was concomitant with another CMV reactivation after the withdrawal of ganciclovir. This case report is an example of DRESS that may be considered real DRESS or virus reactivation with eosinophilia and systemic symptoms (VRESS) as a manifestation of immune reconstitution inflammatory syndrome. The case confirms that herpesvirus reactivation precedes DRESS or VRESS, and suggests the need to monitor herpesvirus infection in patients at risk for the infection or after the initiation of culprit drugs.

Human herpesvirus 6 involvement in paediatric drug hypersensitivity syndrome

“…An increase of CMV viral loads preceded the development of DRESS and subsequent flare during the course of the disease. But, interestingly, at the time of diagnosis of DRESS the CMV was undetectable . Whereas HHV may be detected at the very beginning of DRESS it could not be detected during the first week corresponding to the time of the strongest antiviral immune response.…”

“…HHV detection may be missed. In a recent case report we studied the course of CMV reactivation in a patient infected with human immunodeficiency virus who developed DRESS after the introduction of antiretroviral therapy and antitoxoplasmic drugs . An increase of CMV viral loads preceded the development of DRESS and subsequent flare during the course of the disease.…”

“…But the consequence of systemic corticosteroids on HHV reactivation needs to be evaluated in a large prospective study. The future management of severe DRESS will probably be the administration of corticosteroids along with an antiviral treatment …”

Drug Reaction with Eosinophilia and Systemic Symptoms or Virus Reactivation with Eosinophilia and Systemic Symptoms

“…Herpesvirus (EBV, human herpesvirus-6, cytomegalovirus) primary infection or reactivation may mimic DRESS. We proposed the acronym VRESS (virus reactivation with eosinophilia and systemic symptoms) to highlight this differential diagnosis (2)(3)(4).…”

Drug Reaction with Eosinophilia and Systemic Symptoms or Herpes Virus Infection: Author's Reply

“…Immunoglobulin M(IgM) antibody testing for EBV capsid antigen was performed in all the antibiotic‐induced DRESS cases mentioned in the study since they were referred to us for persistent pyrexia and pruritic rash that appeared after ingestion of penicillin or cephalosporin . The IgM antibody was negative in all, but we did not perform the sequential assay for IgG or IgM antibodies to EBV or evaluate the possibility of infection or reactivation of other herpes viruses . We considered EBV infection to be less likely in our children since it remains subclinical in early age or presents with fatigue, pharyngitis, generalized lymphadenopathy, transaminase elevation, splenomegaly, and atypical lymphocytosis .…”