The DRESS syndrome, formerly known as drug hypersensitivity reaction, is a rare but potentially fatal drug reaction (4). The patient showed the typical biphasic course, which could be traced back to the common reactivation of HHV-6 in the third week.
Our patient with celiac sprue and IDDM may have a genetic predisposition to autoimmunity and drug hypersensitivity. Although this syndrome is not so rare (treatment with antiepileptics 1:3000), the diagnosis is often delayed, as it is hard to imagine that a drug hypersensitivity could cause such a severe disease. Time lapses by in the search for viral infections or an undefined autoimmune disease. However, this can be dangerous, as the most decisive step is stopping the drug!
This is the first report of a DRESS syndrome that can be clearly attributed to gabapentin. In addition, the co-medication with carbamazepine may have induced the hypersensitivity reaction, similar as in a patient with hypersensitivity against phenytoin after co-medication with carbamazepine (5). An hypersensitivity syndrome after medication with gabapentin has been reported in a 72 years old patient with similar clinical findings apart from eosinophilia (6). Moreover several cases of hypersensitivity reactions in patients receiving gabapentin have been brought to the attention of both the manufacturer and the UK Committee on Safety of Medicines. The findings in our patient clearly demonstrate, that gabapentin should be added to the list of drugs that can elicit DRESS.
Prednison treatment seemed to have been helpful in this patient with hepatitis after stopping treatment.
References
(1) Emmenegger U, Schaer DJ, Larroche C, Neftel KA. Haemophagocytic syndromes in adults: current concepts and challenges ahead. Swiss Med Wkly. 2005 May 28;135(21-22):299-314.
(2) Schwartz RN, Stover L, Dutcher J. Managing toxicities of high-dose interleukin-2. Oncology (Williston Park). 2002 Nov;16(11 Suppl 13):11-20.
(3) Pichler WJ, Tilch J. The lymphocyte transformation test in the diagnosis of drug hypersensitivity. Allergy 2004: 809-820
(4) Tas S, Simonart T. Management of drug rash with eosinophilia and systemic symptoms (DRESS syndrome): An update. Dermatology 2003; 206: 353-356
(5) Klassen BD, Sadler RM. Induction of hypersensitivity to a previously tolerated antiepileptic drug by a second antiepileptic drug. Epilepsia 2001;42:433-5.
(6) Ragucci MV, Cohen JM. Gabapentin-induced hypersensitivity syndrome. Clin. Neuropharmacology 2001: 2: 103-105
Summary
One of the most severe forms of drug hypersensitivity reactions is the drug hypersensitivity syndrome, formerly also called the anticonvulsant hypersensitivity syndrome. A new name – DRESS – pinpoints the hallmarks of this syndrome – namely drug rash (reaction) with eosinophilia and systemic symptoms (like hepatitis, nephritis, pneumonitis, pancreatitis, or colitis). It can be caused by antiepileptics, allopurinol, sulfasalazine and some other drugs. Ten to 30% of the patients may die and some require liver transplantation. The most important step is stop of drug treatment. In spite of this, the course of this disease may be prolonged, as often a reactivation of herpes viruses can be observed in the third/fourth week. Typical is also a hypersensitivity to other drugs with flare up reactions (exanthema, hepatitis) for months. Therefore, patients should avoid any unnecessary contact with xenobiotics, in particular antibiotics, until the massive immune stimulation has weaned.
|
