Síndrome DRESS inducido por ácido valproico en una niña que respondió a la ciclosporina con análisis de HLA / Valproic acid-induced DRESS in a child responding to cyclosporine with HLA analysis

El síndrome de erupción medicamentosa con eosinofilia y síntomas sistémicos (drug reaction with eosinophilia and systemic symptoms, DRESS), también conocido como síndrome de hipersensibilidad inducida por medicamentos, es una reacción rara potencialmente mortal que causa una erupción grave y que puede provocar insuficiencia multiorgánica. Como con otras erupciones medicamentosas graves, los linfocitos T específicos para un medicamento tienen una función crucial en el síndrome DRESS. El modelo de hapteno/pro-hapteno, el modelo de interacción farmacológica y el modelo alterado de repertorio de péptidos son tres modelos diferentes desarrollados para describir la relación/interacción entre un medicamento o sus metabolitos y el sistema inmunitario. Analizamos nuestra experiencia con el tratamiento con ciclosporina en un caso de síndrome DRESS resistente a esteroides causado por ácido valproico en una niña y sus resultados clínicos, de laboratorio y de antígeno leucocitario humano (HLA).

Drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome, is a potentially life-threatening rare reaction that causes a severe rash and can lead to multiorgan failure. As in other severe drug eruptions, drug-specific T lymphocytes play a crucial role in DRESS. The hapten/pro-hapten model, pharmacological interaction model, and altered peptide repertoire model are three different models developed to describe the relationship/interaction between a medication or its metabolites and the immune system. We discuss our experience with cyclosporine treatment in a steroid-resistant DRESS syndrome caused by valproic acid in a girl, as well as her clinical, laboratory, and human leukocyte antigens (HLA) study results

Síndrome de DRESS inducido por sulfasalazina. ¿Consideramos esta reacción adversa grave al indicar el fármaco? Caso clínico

DRESS syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms) is a severe, rare and potentially lethal idiosyncratic condition associated with the use of some drugs. Given its broad spectrum of presentation, clinical suspicion is essential for management, since it requires the immediate withdrawal of the culprit drug, support measures and the use of corticosteroids as the first line of treatment. We report a 24-year-old woman with a diagnosis of ulcerative colitis with joint involvement despite the use of infliximab, who presented symptoms, signs and laboratory compatible with DRESS syndrome on the third week after indicating sulfasalazine for her baseline disease.

Factores de riesgo asociados a la meningitis eosinofílica causada por Angiostrongylus cantonensis (Nematoda: Metastrongylidae) en Chone, Ecuador / Risk factors associated to eosinophilic meningitis caused by Angiostrongylus cantonensis (Nematoda: Metastrongylidae) in Chone, Ecuador

Introducción: El parásito Angiostrongylus cantonensis es el principal causante de meningitis eosinofílica. En el 2008 se reportó el primer caso en Ecuador y un estudio reciente en la Ciudad de Chone, Manabí, Ecuador determinó una alta prevalencia del parásito en el caracol africano (Achatina fulica). Objetivo: Identificar los factores de riesgo asociados a la meningitis eosinofílica causada por A. cantonensis en la ciudad de Chone. Métodos: Se entrevistaron a 500 personas residentes en la ciudad de Chone y se revisaron las historias clínicas del Hospital General de Chone. Resultados: Se observó que la población de Chone, está expuesta a los siguientes factores de riesgos: consumo de caracoles crudos (7,40 por ciento), el frecuente contacto de las personas con el caracol africano en la casa (67 por ciento), como en el trabajo (51,20 por ciento), el contacto que tienen los niños con caracoles, al jugar en el jardín (76,80 por ciento) y la incorrecta limpieza de los alimentos (54,40 por ciento). En el entorno de la población, se evidenció la presencia del caracol africano cerca de las casas en el 35,20 por ciento y las ratas, en el 50,80 por ciento. Además, el 34 por ciento de la muestra de estudio presentó sintomatología relacionada con meningitis eosinofílica. Se encontró que existía asociación entre la presencia de vectores cerca de las casas y la cantidad de síntomas manifestados por las personas. Conclusiones: Se evidenció que la población de Chone, manifiesta hábitos que exponen a la gente de esta localidad a un alto riesgo de contagio de meningitis eosinofílica(AU)

Introduction: The parasite Angiostrongylus cantonensis is the main causative agent of eosinophilic meningitis. The first case in Ecuador was reported in 2008, and a recent study conducted in the city of Chone, Manabí, Ecuador, determined a high prevalence of the parasite in the African snail (Achatina fulica). Objective: Identify the risk factors associated to eosinophilic meningitis caused by A. cantonensis in the city of Chone. Methods: Interviews were conducted with 500 residents from the city of Chone and a review was carried out of the medical records at Chone General Hospital. Results: It was found that the population of Chone is exposed to the following risk factors: eating raw snails (7.40 percent), frequent contact between people and African snails both at home (67 percent) and at work (51.20 percent), contact between children and snails while playing in gardens (76.80 percent) and washing food items incorrectly (54.40 percent). In the areas surrounding people's households the African snail was found in 35.20 percent and rats in 50.80 percent . Additionally, 34 percent of the study sample had symptoms of eosinophilic meningitis. An association was found between the presence of vectors near the houses and the number of symptoms occurring in people. Conclusions: It was evident that the population of Chone has habits which expose them to a high risk for eosinophilic meningitis(AU)

Síndrome de hipersensibilidad a medicamentos con exantema, eosinofilia y síntomas sistémicos inducido por carbamazepina / Drug rash with eosinophilia and systemic symptoms syndrome induced by carbamazepine: Case report

RESUMEN El síndrome de hipersensibilidad a medicamentos, con exantema, eosinofilia y síntomas sistémicos (Drug Rash Eosinophylia with Systemic Symptoms, DRESS) es una reacción a diferentes medicamentos, principalmente anticonvulsivos, el cual cursa con compromiso sistémico y lesiones eritematosas, al igual que ocurre en diversas dermatosis por reacción a medicamentos. Este síndrome es una condición clínica poco frecuente, cuyo diagnóstico requiere un alto grado de sospecha por parte del personal clínico. Si no se hace un diagnóstico oportuno y se suministra el tratamiento adecuado, puede confundirse con otros tipos de alergias a medicamentos que implican riesgo de muerte. Se presenta el caso de un paciente de 22 años de edad con alteración del neurodesarrollo a quien se le inició tratamiento con carbamazepina. Dos meses después consultó debido a la aparición de síntomas generales y lesiones eritematosas en la piel, inicialmente en el tronco. En la atención ambulatoria se le prescribieron antihistamínicos y antipiréticos, con los cuales no mejoró adecuadamente; su condición empeoró, con la aparición de lesiones en la piel y síntomas sistémicos propios del síndrome DRESS. Al cabo del tratamiento farmacológico administrado durante su hospitalización según los lineamientos recomendados, las manifestaciones y complicaciones asociadas con el síndrome remitieron, la administración de esteroides pudo reducirse gradualmente y, finalmente, el paciente fue dado de alta.

ABSTRACT Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome is a hypersensitivity reaction associated with a variety of drugs, mainly anticonvulsants, which is characterized by systemic symptoms and erythematous lesions, common to other toxicodermas. It is an uncommon clinical entity that requires a high suspicion by clinical staff given its varied initial presentation, and the fact that symptoms can overlap with those of other adverse cutaneous reactions to drugs. Without early diagnosis and appropriate treatment, mortality increases. We report the case of a 22-year-old patient with impaired neurodevelopment who received treatment with carbamazepine. Two months later he presented with general symptoms and skin erythematous lesions that began on his trunk. The patient received outpatient care with antihistamines and antipyretics without an appropriate response. His case progressed with increased skin lesions and systemic symptoms that met the diagnostic criteria for DRESS syndrome. He was hospitalized and received medical treatment according to recommended guidelines. The patient's condition improved as his symptoms and associated complications resolved. He was discharged with gradual clearing of the steroid therapy.

Drug reaction with eosinophilia and systemic symptoms (DRESS syndrome) / Reação a drogas com eosinofilia e sintomas sistêmicos (síndrome DRESS)

SUMMARY Objective: To review the hypersensitivity reaction to drugs known as drug reaction with eosinophilia and systemic symptoms (DRESS syndrome), based on a case report. We also intend to discuss the difficulty and importance of disease recognition, since none of the changes is pathognomonic of this disease and failure to identify it may have disastrous consequences for the patient. Method: To describe this case report, in addition to the information collected for clinical assessment, a literature review was performed in the PubMed and Bireme databases in order to retrieve the latest information published in literature on DRESS syndrome. Results: The case of a 20-year old patient is reported. After anamnesis, physical examination and laboratory tests a diagnosis of DRESS syndrome was performed, characterized by rash, hematologic alterations, lymphadenopathy and lesions in target organ. This is a rare syndrome, whose frequency varies according to the drug used and the immune status of the patient, being more often associated with the use of anticonvulsants. Conclusion: The approach and discussion of the topic are of paramount importance, in view of the potential lethality of this treatable syndrome. Recognizing the occurrence of DRESS syndrome and starting treatment as soon as possible is crucial to reduce the risk of mortality and improve prognosis.

RESUMO Objetivo: fazer uma revisão da reação de hipersensibilidade a drogas denominada reação a drogas com eosinofilia e sintomas sistêmicos (síndrome DRESS), com base em um relato de caso clínico. Pretende-se ainda discutir a dificuldade e importância de seu reconhecimento, uma vez que nenhuma alteração dessa doença é patognomônica e sua não identificação pode trazer consequências desastrosas para o paciente. Método: para descrever este relato, além das informações coletadas no caso clínico, uma revisão da literatura nas bases de dados PubMed e Bireme foi realizada com o intuito de rever as informações mais recentes publicadas na literatura acerca da síndrome DRESS. Resultados: relatou-se o caso de uma paciente de 20 anos de idade que, após anamnese, exame físico e exames laboratoriais, foi diagnosticada com síndrome DRESS, caracterizada por erupção cutânea, alterações hematológicas, linfonodomegalia e lesões em órgão-alvo. É uma síndrome rara, cuja frequência varia conforme a droga utilizada e o estado imunológico do indivíduo, sendo mais associada ao uso de anticonvulsivantes. Conclusão: a abordagem e discussão do tema são de extrema importância, tendo em vista o potencial de letalidade dessa síndrome, que possui tratamento. Reconhecer precocemente a DRESS e instituir terapêutica é fundamental para reduzir o risco de mortalidade e melhorar o prognóstico.

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

BACKGROUND: Cutaneous 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. OBJECTIVES: To assess the clinical and epidemiological aspects of severe cutaneous adverse reactions to drugs in a tertiary hospital in Porto Alegre, Brazil. METHODS: All 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. RESULTS: An 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. CONCLUSIONS: The 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. .

Meningoencefalitis aséptica como manifestación de un síndrome de rash con eosinofilia y síntomas sistémicos asociados a drogas por lamotrigina / Aseptic meningoencephalitis as infectation of a sindrome of rash with eosinophilia and systemic symptoms associated with drugs caused by lamotrigine

Aseptic meningitis (AM) is defined by the presence of cerebrospinal fluid findings consistent with meningitis, without achieving the isolation of a bacterium that produces it. Drugs are one of the diverse causes of AM. Drugs frequently associated with AM include immunoglobulin's, nonsteroidal anti-inflammatory, antibiotics, and aromatic anticonvulsants. When AM is part of a systemic response accompanying a cutaneous manifestation it may be a DRESS (Drug Rash with Eosinophilia and Systemic Symptoms), considered a serious adverse reaction to drugs. Lamotrigine is a non-aromatic anticonvulsant widely used for the treatment of epilepsy and bipolar disorder, which has been associated with AM. We report a case of aseptic meningoencephalitis as a manifestation of DRESS associated to lamotrigine.

La meningitis aséptica (MA) se define por la presencia de hallazgos en el líquido cefalorraquídeo compatibles con una meningitis, sin que se logre aislar una bacteria que la produzca. Las causas de MA son diversas, entre las que se encuentran las drogas. Entre los fármacos que más frecuentemente se han asociado a MA, se encuentran los antiinflamatorios no esteroidales, antibióticos, inmunoglobulinas y anticonvulsivantes aromáticos. Cuando la MA forma parte de una respuesta sistémica que acompaña a una manifestación cutánea, puede tratarse de un rash con eosinofilia y síntomas sistémicos asociado a drogas (DRESS, acrónimo derivado del inglés DrugRash with Eosinophilia and Systemic Symptoms), considerada una reacción adversa grave a medicamentos. La lamotrigina es un anticonvulsivante no aromático ampliamente utilizado para el tratamiento de la epilepsia y el trastorno bipolar que ha sido asociada con MA. Comunicamos un caso de meningoencefalitis aséptica como manifestación de DRESS asociado al uso de lamotrigina.

DRESS: clinicopathological features of 10 cases from an University Hospital in São Paulo / DRESS: características clinicopatológicas em 10 casos de Hospital Universitário em São Paulo

BACKGROUND: Drug reaction with eosinophilia and systemic symptoms is a severe form of drug-induced reaction with multiorgan involvement. OBJECTIVES: The aim of this study is to evaluate the epidemiological, clinical and pathological features and prognosis of this drug reaction among patients seen at a dermatology service. METHOD: Retrospective review of medical records of ten patients diagnosed with drug reaction with eosinophilia and systemic symptoms at the Federal University of São Paulo, from august 2008 to may 2011. RESULTS: Phenytoin was the leading cause of drug reaction with eosinophilia and systemic symptoms in our cases, followed by allopurinol. Abnormal liver function tests were observed in 7 patients and renal function impairment in 2 patients. In all cases, patients were hospitalized and the culprit drug was withdrawn. The main treatment was systemic corticosteroid. Drug reaction with eosinophilia and systemic symptoms resulted in death in 2 cases. The causes of death were septic shock and hepatic failure. CONCLUSION: Our mortality rate of 20%, supports that drug reaction with eosinophilia and systemic symptoms is a severe form of drug-induced reaction and must be recognized by all dermatologists.

FUNDAMENTOS: A reação a droga com eosinofilia e sintomas sistêmicos é uma reação medicamentosa severa com envolvimento de múltiplos órgãos. OBJETIVO: Avaliar as características epidemiológicas, clínicas, histológicas e o prognóstico dessa reação medicamentosa entre os pacientes atendidos pelo serviço da dermatologia. MÉTODOS: Levantamento retrospectivo dos prontuários de dez pacientes diagnosticados com reação a droga com eosinofilia e sintomas sistêmicos pelo serviço de dermatologia da Universidade Federal de São Paulo, entre agosto de 2008 e maio de 2011. RESULTADOS: A fenitoína foi a principal causa de reação a droga com eosinofilia e sintomas sistêmicos entre os pacientes, seguida pelo alopurinol. A alteração das enzimas hepáticas foi observada em sete pacientes e diminuição da função renal em dois casos. Todos os pacientes estavam hospitalizados e o medicamento implicado foi suspenso. O principal tratamento foi corticóide sistêmico. Dois pacientes faleceram devido à síndrome reação a droga com eosinofilia e sintomas sistêmicos. A causa da morte foi choque séptico e falência hepática. CONCLUSÃO: A mortalidade de 20% entre os pacientes do estudo confirma que essa reação induzida por droga é grave e deve ser reconhecida por todos os dermatologistas.

Penicillin V-induced drug rash with eosinophilia and systemic symptoms / Erupción cutánea inducida por la penicilina V con eosinofilia y síntomas sistémicos

DRESS syndrome (drug reaction with eosinophilia and systemic symptoms), previously named "drug hypersensitivity syndrome", is a severe adverse drug reaction characterized by skin rash, fever, lymph node enlargement and internal organ involvement. We report on a 7-year old girl who developed DRESS syndrome caused by penicillin V treatment.

El síndrome DRESS (así llamado por las indíciales del inglés "drug reaction with eosinophilia y systemic symptoms ") es una reacción a medicamentos, acompañada por eosinofilia y síntomas sistémicos. Conocida anteriormente como "síndrome de hipersensibilidad a los medicamentos, se trata de una reacción adversa severa a los medicamentos, caracterizada por erupción cutánea, fiebre, agrandamiento de los ganglios y compromiso de órganos internos. El presente trabajo reporta el caso de una niña de 7 años de edad, que desarrolló el síndrome DRESS a partir de un tratamiento con penicilina V.

Síndrome de DRESS: experiencia en un hospital pediátrico / DRESS syndrome: experience in a pediatric hospital

El síndrome de DRESS es una reacción grave de hipersensibilidad a drogas caracterizada por exantema, fiebre adenopatías, afectación de órganos internos y alteraciones hematológicas. Objetivos: 1. Describir las características clínicas y alteraciones de laboratorio de los pacientes con diagnóstico de síndrome de DRESS, evaluados en nuestro Servicio desde enero de 2004 hasta agosto de 2009. 2. Detallar los fármacos responsables del mismo. 3. Describir la evolución de estos pacientes así como también los tratamientos instaurados. Resultados: Se seleccionaron 14 pacientes. El 71% presentó fiebre como primer signo clínico, el exantema se encontró en el 100%, el edema de cara en el 57% y el 71% desarrolló hepatitis durante la internación. La eosinofilia fue hallada en el 79% de los pacientes y un 43% presentó linfocitos atípicos. Los anticonvulsivantes fueron los fármacos responsables más frecuentes. Todos los pacientes recibieron antihistamínicos. El 71% recibió, además, corticoides sistémicos, mientras que la gammaglobulina fue indicada en el 21% de los pacientes en forma concomitante con los corticoides. Conclusiones: Observamos que el rash, la fiebre y el edema de cara constituyen signos clínicos primarios en esta patología, por lo cual ente un paciente con estas características sumado al antecedente de ingesta de un fármaco sospechoso se deberá buscar compromiso de órganos internos para descartar síndrome de DRESS.

Rat subcutaneous tissue response to modified Portland Cement, a new mineral trioxide aggregate

The purpose of this study was compare the biocompatibility of modified Portland cement (CPM) and mineral trioxide aggregate (MTA) in a subcutaneous rat model. Twenty-four male Wistar rats were used. Three silicon tubes were placed on the dorsal subcutaneous tissue of each animal: one tube contained MTA, one tube contained CPM and the other was an empty tube. The rats were sacrificed in 3 groups of 8 animals at 7, 14 and 30 postoperative days, respectively. Tissue samples were fixed in 10 percent buffered formalin, embedded in paraffin, and serial sections were cut and stained with hematoxylin and eosin, Masson Trichrome and Luna's stain. At day 7, the empty tubes displayed a mild inflammatory infiltrate. In the CPM group, an inflammatory infiltrate was observed with some eosinophils and immature connective tissue. The MTA group showed a similar infiltrate without eosinophils and presence of abundant necrotic tissue and numerous multinucleate foreign body giant cells. At day 14, the chronic infiltrate with eosinophils persisted when in contact with CPM. In the MTA group, necrosis and distant giant cells could still be seen. At day 30, all 3 groups showed mature fibrous collagenous tissue. These findings indicate a different response to the materials evaluated in this study. Although, MTA and CPM induced a chronic inflammatory infiltrate, necrosis and multinucleated foreign body giant cells predominated in the MTA group, while in the CPM group numerous eosinophils were seen at all the observational periods.

O propósito deste estudo foi comparar a biocompatibilidade do cimento Portland modificado (CPM) com agregado de trióxido mineral (MTA) no subcutâneo de um modelo murino. Foram usados 24 ratos Wistar macho. No tecido subcutâneo dorsal de cada animal se colocaram 3 tubos de silicone. Um contendo MTA, outro CPM e o último vazio. Os animais foram sacrificados em 3 grupos de 8 aos 7, 14 e 30 dias. As amostras se fixaram em formol e se coloriram com hematoxilina - eosina, Masson e Luna. No dia 7 os tubos vazios mostraram uma leve infiltração de células inflamatórias. No grupo CPM, se observou um infiltrado inflamatório com alguns eosinófilos e tecido conectivo imaturo. O grupo MTA mostrou um infiltrado similar sem eosinófilos e abundante necrose de tecido e numerosas células gigantes multinucleadas do tipo corpo estranho. Ao dia 14, o infiltrado crônico com eosinófilos persistiu em contato com CPM. No grupo MTA, a necrose e células multinucleadas afastadas ainda se podiam observar. Ao dia 30, os 3 grupos mostraram tecido fibroso maduro. Estes resultados mostram uma resposta diferente aos materiais avaliados no presente estudo. Apesar do que MTA e CPM causaram um infiltrado crônico, no grupo MTA predominou a necrose e as células gigantes, enquanto isso, no grupo CPM se observaram grandes quantidades de eosinófilos.

Drogas asociadas a enfermedad pleural / Associated drugs to pleural disease

Está bien documentado que las drogas pueden producir enfermedades de la pleura. Si bien hay alrededor de treinta drogas a las que se las relaciona claramente con afectación pleural, también hay que considerar que toda droga puede, potencialmente, comprometer la pleura y, si no hay otra causa evidente de enfermedad pleural, se debe tener presente esta causa. El daño puede darse en forma independiente en la pleura o coexistir con el del parénquima pulmonar. La mayoría de los casos se resuelve al suspender la droga y, en otras ocasiones, se deben agregar esteroides. En este artículo se realiza un agrupamiento de las drogas que producen esta patología, una descripción y las características de cada una de ellas, y el manejo terapéutico adecuado de las que más frecuentemente se hallan involucradas.

It's well known that drugs can produce pleural diseases. There are about thirty drugs which are associated with them, but any drug, potentially, may cause pleural disease. Pleural damage may happen as an independent form or coexists with pulmonary parenchyma injury. Most cases are resolute when drug is discontinued, but every times we have to add steroids. In this article we group them, their characteristics are described, and we give a treatment guide of more common drugs which cause pleural diseases.

Efectos de exposición aguda a cadmio en la acción de estrógenos en útero de rata impúber / Effects of acute exposure to cadmiun on response to estrogen in the prepuberal rat uterus

Background: Few information is available about uterine effects of Cadmium (Cd) exposure, where toxic agents affecting the female genital tract interact with estrogen (E) receptors, modifiying myometrial activity and the menstrual cycle, causing dysmenorrhea, infertility and spontaneous abortion. No information exists whether prenatal or early postnatal exposure may cause any gynecologic persistent adverse effect. Our finding of a second mechanism of E interaction and differences between E receptors in the various uterine cell types suggests that Cd may affect differently E interaction in each cell-type. Objective: Evaluate a possible selective effect of acute Cd exposure on E action in the uterus during prepuber age. Method: Female prepuber rats exposed to Cd 4 mg/kg and 2 hours later, treated with Estradiol-17² 0,3 mg/kg. A myometrial sample was obtained under anaesthesia 24 hours after E treatment and histologically processed for the quantification of E responses on different uterine cell-types. Results: Cd exposure potentiates E-induced uterine eosinophilia and endometrial edema and inhibits E-induced cell hypertrophy in circular myometrium and cell proliferation in luminal myometrium. Cd, in the absence of hormone stimulation, causes a slight cell hypertrophy in circular myometrium. Conclusions: Acute exposure to Cd affects differently various responses to E in the different uterine cell-types. Future studies should verify whether this effect explains Cd-induced infertility, postpubertal sex organ development and whether prenatal or early postnatal exposure to Cd induces delayed persistent effects.

Antecedentes: Existe poca información sobre efectos del cadmio (Cd) en el útero. En mujeres altera la actividad miometrial, el ciclo menstrual y causa dismenorrea, abortos espontáneos, infertilidad y mortinatos. No existe información si la exposición prenatal o postnatal temprana causa efectos ginecológicos diferidos persistentes. Los tóxicos que afectan el útero suelen interactuar con receptores de estrógeno (E). Nuestro hallazgo de un segundo mecanismo de acción de E y de diferencias entre receptores de E de los diversos tipos celulares uterinos hacen posible que el Cd interactúe con los E en forma diferente en cada tipo celular. Objetivos: Buscar un posible efecto selectivo de la exposición aguda a Cd con algunas respuestas a E en útero de rata durante la edad prepuberal. Métodos: Ratas hembra impúberes recibieron 4 mg Cd/kg p.c. y 2 h después se trataron con 0,3 mg estradiol-17(3/kg p.c; los úteros fueron obtenidos bajo anestesia a las 24 h del tratamiento con E. Los úteros se procesaron para la cuantificación de respuestas a E en cada tipo celular por separado. Resultados: La exposición a Cd incrementa la eosinofilia uterina y edema endometrial inducidos por E; inhibe las siguientes respuestas a E: hipertrofia celular en miometrio circular, proliferación celular en epitelio luminal y miometrio. En ausencia de hormona, el cadmio causa una leve hipertrofia celular en miometrio circular. Conclusiones: La exposición aguda a Cd afecta de manera diferente las respuestas a E en los diversos tipos celulares uterinos de rata prepuberal. Futuros estudios deberán verificar si este efecto explica la infertilidad causada por exposición a Cd, afecta el desarrollo postpuberal de los órganos sexuales, e investigar si la exposición prenatal o postnatal temprana induce efectos diferidos persistentes, como puede ocurrir en población infantil prenatalmente expuesta a Cd.

Sulfasalazine-induced DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms) / Síndrome DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) induzida por sulfasalazina

CONTEXT: DRESS syndrome (Drug Rash with Eosinophilia and Systemic Symptoms) is a type of drug reaction commonly mistaken for a viral infection. It must be recognized promptly due to its high morbidity and 10 percent mortality rate. Few cases of DRESS syndrome induced by sulfasalazine have been reported in the literature. CASE REPORT: The case of a 47-year-old white Brazilian woman who developed DRESS syndrome eight weeks after starting a course of sulfasalazine for treatment of seronegative arthritis is reported. She presented a skin rash, fever, hepatitis, lymphadenopathy, eosinophilia and atypical lymphocytes. The causative drug was discontinued immediately, but she only improved after treatment with prednisone.

CONTEXTO: A síndrome DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) é um tipo de reação a drogas comumente confundida com uma infecção viral. Deve ser prontamente reconhecida devido a sua alta morbidade e taxa de mortalidade de 10 por cento. Poucos casos de síndrome DRESS induzida por sulfasalazina foram relatados na literatura. RELATO DE CASO: É relatado o caso de uma mulher branca, brasileira, de 47 anos, que desenvolveu a síndrome DRESS oito semanas após iniciar tratamento com sulfasalazina para artrite soronegativa. A paciente apresentou rash maculopapular, febre, hepatite, linfadenomegalia, eosinofilia e linfocitose atípica. A medicação foi suspensa imediatamente no início dos sintomas, mas só houve melhora clínica após tratamento com prednisona.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) Syndrome Induced by Celecoxib and Anti-tuberculosis Drugs

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome reflects a serious hypersensitivity reaction to drugs, characterized by skin rash, fever, lymph node enlargement, and internal organ involvement. So far, numerous drugs such as sulfonamides, phenobarbital, sulfasalazine, carbamazepine, and phenytoin have been reported to cause the DRESS syndrome. We report a case in a 29-yr-old female patient who had been on celecoxib and anti-tuberculosis drugs for one month to treat knee joint pain and pulmonary tuberculosis. Our patient's clinical manifestations included fever, lymphadenopathy, rash, hypereosinophilia, and visceral involvement (hepatitis and pneumonitis). During the corticosteroid administration for DRESS syndrome, swallowing difficulty with profound muscle weakness had developed. Our patient was diagnosed as DRESS syndrome with eosinophilic polymyositis by a histopathologic study. After complete resolution of all symptoms, patch tests were positive for both celecoxib and ethambutol. Although further investigations might be needed to confirm the causality, celecoxib and ethambutol can be added to the list of drugs as having the possibility of DRESS syndrome.

Eosinophilic leukemoid reaction associated with carbamazepine hypersensitivity.

Carbamazepine is widely used in the treatment of epilepsy, neuralgic pain, and bipolar affective disorders. Several adverse drug reactions have been described during the course of carbamazepine administration, including exanthemata and hematological reactions. Carbamazepine is one of the common drugs that have been implicated in the etiology of drug hypersensitivity syndrome. A 50-year-old male presented with generalized erythroderma following 10 weeks of ingestion of carbamazepine 200 mg daily for idiopathic epilepsy. His systemic examination was within normal limits. Blood counts revealed marked eosinophilia of 52% (absolute eosinophil count of 10,400 per mm3). Bone marrow aspiration revealed a moderate increase in the eosinophilic series with cells showing normal morphology. The eosinophil counts returned to normal after 2 weeks of oral prednisolone therapy. This case is reported because of its rarity in the Indian medical literature.

Carbamazepine-induced eosinophilic enteritis.

We describe a 15-year-old boy who was on carbamazepine for the past 8 years for seizure disorder, who developed recurrent episodes of small bowel obstruction. Full-thickness small bowel biopsy obtained at laparotomy was consistent with eosinophilic enteritis. He improved clinically after tapering the drug.