Severe cutaneous reactions to drugs in the setting of a general hospital

Abstract

BACKGROUNDCutaneous drug reactions are frequently found. Assessing the clinical and epidemiological profile of severe forms is extremely relevant for their better recognition and management. Few studies have assessed the severe forms of cutaneous drug reactions in patients hospitalized in our setting. OBJECTIVESTo assess the clinical and epidemiological aspects of severe cutaneous adverse reactions to drugs in a tertiary hospital in Porto Alegre, Brazil. METHODSAll cases of severe cutaneous adverse reactions to drugs in patients hospitalized from January/2005 to December/2010 were retrospectively analyzed for clinical and epidemiological variables. Cases of Stevens-Johnson Syndrome, Toxic Epidermal Necrolysis, drug hypersensitivity syndrome or Drug Reaction with Eosinophilia and Systemic Symptoms and acute generalized exanthematous pustulosis were included. RESULTSAn occurrence rate of 1 serious reaction for every 3,048 inpatients was found (total of 173,767 inpatients admitted in the period). Drug Reaction with Eosinophilia and Systemic Symptoms was the most frequent presentation. The drugs most frequently involved were anticonvulsants (40.4%), antibiotics (26.3%), and analgesics/anti-inflammatory drugs (10.5%). Thirty seven patients (64.9%) were admitted to hospital because of the cutaneous drug reaction. Ten patients (17.5%) died and in most of those (60%), the drug causing the reaction could not be determined. CONCLUSIONSThe frequency of severe cutaneous adverse reactions to drugs in our setting is significant. Drug Reaction with Eosinophilia and Systemic Symptoms seems to be the most frequent presentation of severe cutaneous drug reactions. Most patients developed cutaneous drug reactions outside the hospital. Mortality rates were higher for Toxic Epidermal Necrolysis and this presentation significantly affected older people. Not knowing the drug causing the reaction was related to mortality.

Eosinophilia

“…In reviews of 2 large, hospital-based cohorts of monitored drug allergies in Brazil and Malaysia, the DRESS syndrome was caused mainly by antibiotics, antiepileptics, antigout regimens, antiretrovirals, and nonsteroidal antiinflammatory drugs. 8,9 Stevens-Johnson syndrome and toxic epidermal necrolysis, severe and life-threating forms of drug allergy, do not usually produce eosinophilia, but rather neutrophilia and lymphocytopenia. Box 2 lists pharmaceuticals commonly implicated in DRESS syndrome.…”

Severe cutaneous adverse drug reactions of Chinese inpatients: a meta-analysis

“…3 The spectrum of SCADRs includes Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug-induced hypersensitivity syndrome (DIHS)/ Drug rash with eosinophilia and systemic symptoms (DRESS). 5 DIHS is a new type of adverse drug reaction (ADR) and is considered a SCADR.…”

Drug rash with eosinophilia and systemic symptoms syndrome induced by carbamazepine: Case report

“…Las pruebas diagnósticas indicadas ante una sospecha de síndrome DRESS incluyen el leucograma, las pruebas de función hepática y renal, el análisis de orina, y la radiografía de tórax; en todos los casos, se deben descartar, además, las posibles causas infecciosas (4,6,(8)(9)(10).…”

“…Los diagnósticos diferenciales del síndrome DRESS incluyen otras erupciones causadas por medicamentos, como el síndrome de Stevens-Johnson o la necrólisis epidérmica tóxica, las cuales se caracterizan por la aparición de leucopenia y linfopenia, en contraste con la marcada eosinofilia y la presencia de linfocitos atípicos predominantes en el síndrome DRESS (6). Considerando que en su primer episodio este síndrome puede confundirse con una amplia gama de enfermedades eritematosas, como el lupus eritematoso inducido por medicamentos, la enfermedad de Kawasaki y el sarampión con compromiso hepático (17), resulta imprescindible hacer un diagnóstico preciso de la enfermedad para administrar el tratamiento adecuado.…”

“…Entre los fármacos anticonvulsivos más frecuentemente relacionados con el síndrome, se encuentran la carbamazepina (27 %), el alopurinol (11 %), la lamotrigina (6 %), el fenobarbital (6 %) y la fenitoína (4 %) (5,6), medicamentos que son utilizados en el tratamiento antiepiléptico, la neuralgia del trigémino, el trastorno bipolar e, incluso, la hiperuricemia. El síndrome se produce en muy pocos de los pacientes tratados con estos medicamentos, y su prevalencia y gravedad varían (7).…”