12/3/22, 16:53 Allopurinol-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome complicated by acute renal

e renal failu…

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Cochrane Central Register of Controlled Trials

Allopurinol-induced drug reaction with eosinophilia and systemic symptoms
(DRESS) syndrome complicated by acute renal failure
Khan B, Newton L
Rheumatology (united kingdom), 2019, 58, iii171‐iii172 | added to CENTRAL: 31 August 2019 | 2019 Issue 08
https://doi.org/10.1093/rheumatology/kez110.028

Sourced from: Embase

Abstract

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare, potentially life‐threatening
hypersensitivity reaction. Commonly associated drugs causing DRESS are antiepileptics, antimicrobial, sulphonamides
and occasionally allopurinol. Methods: We report a case of allopurinol‐induced DRESS complicated by end organ
damage, in a patient with suspected gouty arthritis. Results: A 77 years old female with hypertension on losartan was
seen by her GP for intermittent swelling and pain in both knees and first metatarsopharyngeal (MTP) joints for two
months. She had had similar symptoms one year ago, her uric acid level then was 745 umol/l (200‐ 430 umol/l).
Examination showed swollen MTP joints. She was prescribed allopurinol 100mg for gout. It was escalated by 100mg
weekly to 300mg. Four weeks later, she presented with a pruritic rash on her arms with a dry cough. She was diagnosed
with a viral illness and allopurinol was continued. However, a week later she was admitted to hospital with a generalised
erythematous pruritic rash with peeling coalescing papules, cervical lymphadenopathy and high‐grade fever. Her blood
work‐up was abnormal for leucocytosis, neutrophilia, eosinophilia and lymphocytosis. She had a normal eGFR. Skin
biopsy demonstrated superficial perivascular dermatitis with plasma cells and eosinophils and papillary dermal
oedema consistent with drug reaction. Thus, allopurinol was discontinued and prednisolone 20mg commenced with
tapering regime. Her symptoms and her abnormal blood results improved gradually, and she was discharged home.
Unfortunately, two weeks later she was readmitted with acute renal failure requiring dialysis. Conclusion: DRESS
syndrome, a type‐IV delayed hypersensitivity reaction, is a severe and potentially life‐threatening condition

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12/3/22, 16:53 Allopurinol-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome complicated by acute renal failu…

characterised by severe skin rash, fever, lymph node enlargement, haematologic derangements (eosinophilia or
mononucleosis like atypical lymphocytes) and organ failure. The most common internal organ involved is the liver and
to a lesser extent the kidneys, lungs and brain. Pathogenesis of the condition is unclear. Risk factors identified include
recent initiation of allopurinol, co‐prescription of diuretics, impaired renal function and presence of HLA‐B∗5801
alleles. Prompt recognition and withdrawal of causative agent provides complete resolution. For severe involvement,
there are no randomised trials for immune‐suppression but the consensus is for systemic corticosteroids for pulmonary
or renal involvement. This case highlights the importance of early recognition of potential drug side effects to allow
prompt cessation of the causative agent. Patient and general physician education regarding allopurinol may reduce the
severity and improve the outcome of drug reactions including DRESS when they occur. Whether the rapid dose
escalation of allopurinol compared to BSR and EULAR guidelines was a contributory factor is unknown. Although DRESS
is a rare entity, this case is important given the common use of allopurinol, and the consideration of treatment for
asymptomatic hyperuricemia, which should be based on the individual's risks and benefits.

Information

DOI of original publication:

https://doi.org/10.1093/rheumatology/kez110.028 Copy DOI
Database:
Cochrane Central Register of Controlled Trials (CENTRAL)
Date Added to CENTRAL:
31 August 2019
Issue Added to CENTRAL:
2019 Issue 08
Source:
Rheumatology (united kingdom)
Year of Publication:
2019
Volume:
58
Pages:
iii171‐iii172
Correspondence Details:
Rheumatology, Royal Blackburn Hospital, United Kingdom
Conference Details:
2019 Annual Conference of the British Society for Rheumatology, BSR 2019. Birmingham. United
Kingdom. 2019‐04‐30 to 2019‐05‐02.
Accession Number:
EMBASE 628383921
Language:

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12/3/22, 16:53 Allopurinol-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome complicated by acute renal failu…

English
Publication Type:
Journal: Conference Abstract
ID Number:
CN-01959717

Keywords

Embase Keywords

*acute kidney failure; adverse drug reaction; aged; allele; brain; case report; cervical lymphadenopathy; clinical article;
complication; conference abstract; consensus; coughing; delayed hypersensitivity; dermatitis; dialysis; *DRESS
syndrome; drug therapy; drug withdrawal; edema; education; eosinophil; estimated glomerular filtration rate; female;
general practitioner; gout; human; human cell; hypertension; hyperuricemia; immunosuppressive treatment; knee;
liver; lung; lymph node hyperplasia; lymphocytosis; mononucleosis; neutrophilia; organ injury; pain; papule; plasma
cell; practice guideline; prescription; prurigo; randomized controlled trial; remission; risk factor; side effect; skin biopsy;
virus infection

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