Advanced human immunodeficiency virus (HIV) does not affect ability to utilize lymphadenopathy in assessment of drug reaction with eosinophilia and systemic symptoms syndrome in HIV and tuberculosis: Prospective comparative study.

Background: RegiSCAR validation criteria for drug reaction with eosinophilia and systemic symptoms (DRESS) includes lymphadenopathy, a frequent feature of both tuberculosis (TB) and human immunodeficiency virus (HIV). TB is the most common HIV-associated coinfection. Advanced HIV is associated with lymph node (LN) fibrosis. It is not clear if this negatively affects case validation in HIV-associated DRESS. To answer this question, we designed a prospective descriptive study to assess lymphadenopathy in various combinations of comorbid HIV, TB, and DRESS. Objectives: We sought to describe the prevalence of DRESS-associated lymphadenopathy and characterize LN quality, size, and distribution in a high HIV-TB burden setting over time. Methods: We prospectively and systematically examined LN in 25 consecutive acute DRESS cases hospitalized at a South African tertiary-care center and 10 hospitalized non-DRESS HIV-TB coinfected controls. Results: Fourteen (56%) of 25 patients were HIV infected, with a median (interquartile range) CD4 count of 254 (66-478) cells/mm³, and 7 of 14 were coinfected with TB. Using RegiSCAR criteria, 12 (46%) of 25 were definite DRESS cases, 8 (31%) of 25 probable, and 5 (23%) of 25 possible. Possible cases were excluded in the analysis. Fifteen (75%) of 20 subjects had LN in ≥2 anatomic sites, including all 7 patients with HIV-TB coinfection. In contrast, 1 (20%) of 5 hospitalized non-DRESS HIV-TB coinfected controls had LN. Cervical LN, in 15 (88%) of 17, was most common, followed by axillary (76%) and inguinal (59%). Cervical LN ranged between 1 and 2 cm in size. Among the 8 (32%) of 25 subjects with follow-up data, LN had regressed in all within 6 weeks of stopping the offending drug and initiating TB treatment. There was no correlation with CD4 cell count and LN. Conclusion: Lymphadenopathy is a common feature of acute DRESS, even among HIV-TB-coinfected patients with advanced immunosuppression.

Delayed skin testing for systemic medications: helpful or not?

Cutaneous adverse drug reactions (CADR) collectively are delayed drug reactions such as morbilliform drug eruption (MDE) and severe cutaneous adverse reactions (SCAR). Whereas MDE may wane over time, be the result of drug viral interactions and be amenable to slow reintroduction or rechallenge, SCAR are HLA class I restricted, T-cell mediated reactions that demonstrate durable immunity and warrant lifelong avoidance. SCAR such as drug reaction with eosinophilia and systemic symptoms (DRESS), Stevens-Johnson syndrome and toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP) and generalized bullous fixed drug eruption (GBFDE) often occur in the setting of multiple drugs dosed together. Collectively, they lead to significant morbidity, mortality and drug safety concerns that could severely limit future treatment options. Currently, no single or combination of diagnostic tests for SCAR such as ex vivo or in vitro testing, in vivo (skin testing) or other adjunctive tests such as HLA typing have 100% negative predictive value. In this "Controversies in Allergy Review Article", we review the current literature on delayed skin testing (patch and delayed prick/intradermal test) and critically assess the evidence base of its utility across different drugs and clinical phenotypes of delayed hypersensitivity reactions.

Management of acute coronary syndromes requiring coronary angiography in patients with drug reaction with eosinophilia and systemic symptoms syndrome induced by iodinated contrast media: two case reports and narrative review.

Background: Hypersensitivity reactions to iodinated contrast media (ICM) are frequently encountered in clinical practice. Severe manifestations, despite being infrequent, can be life-threatening and represent an issue when re-administration of ICM is required. Clear recommendations on prevention and management of relapses are still lacking. Case summary: We present the cases of two patients presenting with acute coronary syndrome requiring urgent coronary angiography, with an anamnesis of ICM-induced drug reaction with eosinophilia and systemic symptoms syndrome. Both patients safely underwent a coronary angiography with the use of a different ICM (iobitridol) to the one linked to hypersensitivity manifestations, after premedication with corticosteroids and H1 antagonists. Discussion: Our experience highlights that in clinical situations in which the use of ICM is urgently needed, premedication with corticosteroids and H1 antagonists together with the choice of an alternative contrast agent (when the culprit is known) represents an effective strategy to perform a potentially life-saving procedure while avoiding serious systemic allergic reactions.

Operating Room Airborne Microbial Load: Non-Scrubbed Staff Apparel Matters.

BACKGROUND: Infection is a leading cause of total joint arthroplasty failure. In previous studies, we found correlations between the level of contamination, concentrations of airborne particles, and the number of staff present. In this study, we focused on the apparel of non-scrubbed operating room (OR) staff to elucidate their contribution to the airborne microbial load. METHODS: We compared hospital-laundered scrubs to disposable coveralls using two methods. 1) Participants entered an isolation chamber with a controlled environment and completed tasks for one hour wearing both the approved and alternative OR attire. Settle plates collected viable contaminants that were shed by the participants during testing. 2) Lab members conducted standardized maneuvers in a functional OR that simulated typical movements of the nurse, anesthesiologist, implant representative, and entering/exiting staff. An airborne particle counter and settle plates were positioned throughout the OR. After one hour, the staff changed apparel and repeated the test. Each session of both phases consisted of two tests by the same individuals on the same day. RESULTS: There was approximately a 10-fold difference in the settlement rate of viable particles between groups when employing the isolation chamber. The settle rate for scrubs was 5,519 ± 1,381 colony-forming units (CFUs)/m2/hour, while the settle rate for coveralls was 505 ± 55 CFUs/m2/hour (P = 0.008). During testing in the OR, 218.7 ± 35 CFUs/m2/hour were captured for scrubs, compared to 50.5 ± 13 CFUs/m2/hour for the coverall (P < 0.01). The concentration of airborne particles collected for scrubs was 4,952.1 ± 495 particles/m3 and 1,065 ± 53 particles/m3 for the coveralls (P < 0.01). This was a 77 and 79% reduction for both measures, respectively. CONCLUSION: The open nature of standard scrubs allows contaminated particles to escape into the OR environment, whereas the one-piece design of the coveralls restricts pathways of escape. The results of this study may be helpful when developing hospital infection prevention policies.

Atypical Presentation of Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) in a Patient on Pembrolizumab: A Case Report.

Pembrolizumab is an immune checkpoint inhibitor that has been associated with numerous immune-mediated adverse effects. Several of these cutaneous side effects may include bullous pemphigoid, Stevens-Johnson syndrome, and drug reaction with eosinophilia and systemic symptoms (DRESS). Other case reports have reported DRESS as a rare side effect of immune checkpoint inhibitors but due to its variable presentation and similarities with other cutaneous diseases, it has proven to be a diagnostic challenge. In addition, no effective methods have been developed to monitor for such adverse skin reactions in patients on immunotherapy. Here, we report a diagnostic challenging case of pembrolizumab-induced blistering lesions that were initially treated as suspected Herpes zoster and/or bullous pemphigoid but further pathology was consistent with DRESS.

Modulation of the biocompatibility of collagen/polyelectrolyte semi-IPN hydrogels with Zn-bioMOFs.

Background and purpose: In this study, we examined the impact of Zn-bioMOF structures on the physical and chemical characteristics as well as the in vitro biocompatibility of a matrix composed of semi-interpenetrating polymeric networks (semi-IPN) made from collagen and L-tyrosine-based polyelectrolytes. Experimental approach: We hydrothermally synthesized L-1, ZIF-8H Zn-bioMOFs, and the Zn-(L-His)2 complex, utilizing L-histidine, a bioactive amino acid, as a ligand. These metal-organic compounds primarily enhance the mechanical properties of the novel composite hydrogels through physical interactions such as hydrogen bonds and dipolar interactions. They also accelerate the gelation process. Composites containing Zn-bioMOFs exhibited greater biocompatibility than the collagen/polyelectrolyte matrix alone, as evidenced by cytotoxicity assays conducted with porcine fibroblasts, human monocytes, and RAW 264.7 cells. Furthermore, the evaluated materials did not exhibit hemolysis. We investigated the influence of Zn-bioMOFs on cell signaling by measuring the levels of crucial cytokines involved in the healing process, such as MCP-1, TGF-ß, IL-10, and TNF-α secreted by human monocytes. Key results: The composite with Zn(L-His)2 promoted the secretion of MCP-1, TGF-ß, and IL-10, while a decrease in TNF-α secretion was observed with the composite containing ZIF-8H. Zn-bioMOFs enhanced certain aspects of the biomedical and physicochemical properties of the composite hydrogels. Conclusion: Although the overall performance of the tested materials did not differ significantly, it is worth noting that the presence of Zn-bioMOFs in biopolymeric hydrogels modulated the metabolic activity of cells important for healing and their cytokine signaling, leading to improved biomedical performance.

ALDRESS: A Retrospective Pilot Study to Develop a Pharmacological Causality Algorithm for Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS).

Background: The drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome represents a severe form of drug hypersensitivity reaction characterized by significant morbidity, mortality, and long-term sequelae, coupled with limited therapeutic avenues. Accurate identification of the causative drug(s) is paramount for acute management, exploration of safe therapeutic alternatives, and prevention of future occurrences. However, the absence of a standardized diagnostic test and a specific causality algorithm tailored to DRESS poses a significant challenge in its clinical management. Methods: We conducted a retrospective case-control study involving 37 DRESS patients to validate a novel causality algorithm, the ALDRESS, designed explicitly for this syndrome, comparing it against the current standard algorithm, SEFV. Results: The ALDRESS algorithm showcased superior performance, exhibiting an 85.7% sensitivity and 93% specificity with comparable negative predictive values (80.6% vs. 97%). Notably, the ALDRESS algorithm yielded a substantially higher positive predictive value (75%) compared to SEFV (51.40%), achieving an overall accuracy rate of 92%. Conclusions: Our findings underscore the efficacy of the ALDRESS algorithm in accurately attributing causality to drugs implicated in DRESS syndrome. However, further validation studies involving larger, diverse cohorts are warranted to consolidate its clinical utility and broaden its applicability. This study lays the groundwork for a refined causality assessment tool, promising advancements in the diagnosis and management of DRESS syndrome.

Empowering advanced clinical practitioners in managing acute dermatological emergencies.

Advanced clinical practitioners (ACPs) encounter patients with acute dermatological presentations ranging from minor to life-threatening conditions in both primary and secondary care settings. However, ACPs often feel unprepared to assess and treat patients with dermatological emergencies. This article aims to provide guidance to trainee and qualified ACPs, whether in acute hospital settings or primary care, in understanding the essential aspects to consider when consulting with patients presenting with acute dermatological emergencies. It also emphasises appropriate referrals to relevant specialties for necessary inpatient or outpatient investigations and ensure prompt treatment.

Acute kidney injury in lamotrigine-induced DRESS syndrome.

We present a case of lamotrigine-triggered DRESS (drug reaction with eosinophilia and systemic symptoms) syndrome with acute kidney injury stage 3. A 17-year-old girl with known epilepsy treated with lamotrigine presented with acute kidney injury as well as skin eruption, fever, and apathy. Extended diagnostics, considering infectious and autoimmune diseases, remained unremarkable. Lamotrigine blood levels were within the target range. Kidney biopsy showed acute interstitial nephritis with tubular necrosis. Methylprednisolone pulse therapy led to an improvement in kidney function; skin eruption and neurological symptoms resolved. During the hospital stay, the girl admitted to inconsistent and variable intake of lamotrigine, occasionally resulting in notable overdosing. This report demonstrates that acute kidney injury in lamotrigine-induced DRESS syndrome is an acute interstitial nephritis with tubular necrosis, an aspect that has not been deeply characterized so far. Additionally, we aim to elevate awareness towards non-adherence as cause of disease, especially among the adolescent population.

Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome to Hemodialysis Polysulfone Membrane.

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a severe and potentially life-threatening hypersensitivity reaction. Although commonly associated with specific drugs, there have been no reports of DRESS syndrome caused by medical devices. We report a unique case of DRESS syndrome linked to a particular hemodialysis membrane during treatment. An 83-year-old man on hemodialysis exhibited fever, rash, and elevated eosinophils. Despite medication changes and consultations with specialists, his condition persisted. A drug-induced lymphocyte stimulation test revealed a positive response to the dialysis membrane. His symptoms and lab results met DRESS syndrome diagnostic criteria. After substituting the membrane and administering glucocorticoids, the patient displayed early improvement. Diagnosing DRESS syndrome is complex due to its varied presentation and lack of specific benchmarks. This instance underscores the need to consider medical devices as potential DRESS syndrome triggers. Enhanced physician awareness can facilitate prompt detection and proper management, ultimately refining patient outcomes.

DRESS syndrome without eosinophilia presented with extensive skin rash and acute respiratory failure.

This case demonstrated the complex pathophysiology of DRESS syndrome presenting with latent human herpes virus infection reactivation due to exposure to sulfasalazine and/or hydroxychloroquine. Patients who do not initially fulfill the diagnostic criteria on admission may evolve and eventually fulfill the criteria. Steroid dose tapering is required to prevent flaring.

Fatal Itching and Failing Liver: A Case Report and Literature Review of Rare, Atypical DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) Syndrome.

DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome is a rare, life-threatening, hypersensitivity reaction. The prolonged course and non-specific symptoms of the condition make diagnosis challenging. We present a case of DRESS syndrome that was misdiagnosed as urticaria. Investigations revealed deranged liver and kidney functions and abnormal blood count. The presented case emphasizes the need to have a high suspicion for DRESS syndrome in patients who present with jaundice, generalized rash, acute renal failure, and acute liver failure.