Save $$$ on Medrol purchased online

Abstract
Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is an adverse drug reaction most commonly associated with aromatic antiepileptic agents. It is characterized by the triad of skin eruption, fever, and systemic involvement, with the latter usually manifesting as hepatitis and lymphadenopathy. (1) Mortality is primarily due to hepatic failure and can be as high as 10%. (2) Formerly referred to by names such as Dilantin hypersensitivity syndrome and anticonvulsant hypersensitivity syndrome, DRESS syndrome is a more precise term since this reaction pattern can be seen with other agents. DRESS syndrome has also been reported in association with sulfonamides, allopurinol, terbinafine, minocycline, azathioprine, and dapsone (3) as well as with several antiretroviral agents such as abacavir and nevirapine. (4,5) We describe a patient with HIV who developed nevirapine hypersensitivity syndrome who was successfully treated with intravenous immune globulin (IVIG).

Related Results

How effective is prophylactic therapy for gout in people with prior attacks?

role of allopurinol in experimental acute necrotizing pancreatitis, The

Desensitization found effective for allopurinol.(Rheumatology)(Brief Article)

Cardiome Acquires Clinical Program; Gout Program Builds on Congestive Heart F…

Interpharm Announces Revenue and Earnings for the Three-Month Period Ended Se…

**********
Case Report
A 38-year-old HIV positive African-American male presented with a 1-week history of a progressive, pruritic skin eruption, malaise, fevers, severe abdominal pain, and dysuria. He had been started on nevirapine 4 weeks previously as part of an antiretroviral regimen. Upon admission, the patient had a temperature of 38.5[degrees]. On physical examination, he was noted to have hepatosplenomegaly, oral ulcers and cervical lymphadenopathy. His skin examination was significant for a widespread, morbilliform eruption, and scattered pinpoint pustules on the chest. His initial laboratory evaluation, as summarized in Table 1, was significant for eosinophilia and elevated liver enzymes. Atypical lymphocytes were noted on a manual differential. His serum chemistries were normal.
A skin biopsy at that time revealed a mixed perivascular infiltrate and scattered eosinophils which was consistent with a drug reaction. The patient was treated with 4 days of intravenous methylprednisolone, 60 mg every 12 hours, with slight improvement in his liver function tests and rash. Methylprednisolone was subsequently discontinued. However, he redeveloped fevers (up to 39[degrees]) with rapid worsening of liver function tests. His cutaneous eruption became more raised and erythematous, and prednisone was then started at 40 mg twice a day. By day 7 of hospitalization, his AST and ALT were 723 and 978, respectively (Table 1). Abdominal ultrasound and CT scan were significant for mild periportal edema. A liver biopsy showed changes which were consistent with hepatocellular injury. Given his progressive deterioration and concern for hepatic failure, he was treated with Intravenous Immune Globulin (IVIG), 1g/kg/day for 2 days, which he tolerated well without side effects. He had prompt resolution of the skin eruption and improvement of the elevated liver function tests by day 2 of treatment (Figure 1). He was discharged in good condition on a 4-week prednisone taper. He remained asymptomatic 1 month thereafter. His liver function tests returned to baseline by that time. He has not had any recurrence during 3 years of follow-up.
Discussion
The constellation of signs and symptoms in this patient is consistent with nevirapine-induced drug rash with eosinophilia and systemic symptoms (DRESS) syndrome. The management of DRESS syndrome should include the immediate withdrawal of the offending drug and the initiation of supportive therapy. Systemic corticosteroids, though considered controversial, are frequently administered in severe cases of DRESS syndrome. (2) There are a few reports of successful treatment with N-acetylcysteine, although this treatment carries its own risks, such as angioedema. (2) When the above modalities fail, as in our patient, adjunctive treatment with IVIG may be useful.
Recently, 4 cases of DRESS syndrome secondary to anticonvulsants that responded to IVIG have been reported. (6,7,8) These were initially treated with corticosteroids. IVIG was dosed 1 g/kg/d for 2 days in a pediatric patient, (6) while in an adult the dose was 0.4 g/kg given in one infusion. (7) The dose of IVIG was unspecified in the other 2 cases. (8) Our patient received 1 gm/kg/day for 2 days, based on the available literature at that time.
Intravenous Immune Globulin (IVIG) is pooled purified human immunoglobulins, composed mostly of immunoglobulin G, but with small amounts of the other globulins present. (9) IVIG, which was first used in the 1950s to treat Bruton’s agammaglobulinemia, is now FDA approved in the treatment of primary immunodeficiencies, immune-mediated thrombocytopenia, Kawasaki disease, bone marrow transplantation, pediatric HIV infection, and chronic B-cell lymphocytic leukemia. IVIG has also been shown to be effective in dermatologic disorders, such as dermatomyositis and immunobullous disorders. (10) In addition, it has been shown to be efficacious in the management of toxic epidermal necrolysis, likely by inhibition of binding of Fas (CD95) to Fas ligand. (11)