DRESS Syndrome (Drug Reaction with Eosinophilia and Systemic Symptoms)

An overview of DRESS, including clinical presentation, causative meds, differential diagnosis, treatment, and prognosis.
Image credits:
Morbilliform rash by Heinz F. Eichenwald, in Public Domain
Eosinophil by Blausen.com staff (2014). "Medical gallery of Blausen Medical 2014". WikiJournal of Medicine, provided under CC BY-SA 4.0
Lungs by Mikael Häggström, in Public Domain
Heart by Bruce Blaus, provided under CC BY-SA 4.0
#eosinophilia #strongmedicine

[@viviankrause4966]

Thank you for sharing your knowledge. My favorite youtube channel! Best regards from a Brazilian nurse.

[@sunving]

Thank you Doctor Strong . I learn new thing from you every time.

[@JABDUDE]

new graphic style is very cool and makes the video easier to follow.

[@felixgoga7330]

Thanks again Strong medicine for the DRESS

[@HuevoBendito]

Very concise and useful, especially for students!

[@AndreeaTrandafirFlagshipMed]

Hi! I'm glad I discovered your channel! I came across this video because yesterday when I was on call I had a similar case. We couldn't exclude an infection, she didn't have eosinophilia, rather lymphocytosis and monocytosis like in a viral infection and we sent the patient to a hospital with infectious disease doctors, dermatologists and many other possibilities to treat the acute patient. I hope she will recover.

[@Rasha.Ishtar]

Thank you

[@rafaelamstud4140]

thank you

[@TheWunder]

I thought this was a video about me for a second.

[@_Athos]

My friend's sister just died today due to this. She just scratched an itchy spot and next they knew, she had a fever, then the next thing, she was in ICU and died the next day. I came here to understand what dress syndrome is as me and my friends are struggling to understand this syndrome. Thank you

[@ofThoughtsandDreams]

I am sorry for your loss. I had it in 2012 and it took years to "recover" and now I have autoimmune issues after having my organs go through everything this video states and your post reminds me of how lucky I am. I am sending a genuinely heartfelt hug to you, even if it's 2 years later.

[@xaaboopinkly]

Thanks sir!

[@storytime6263]

Thank God for you doctors. So many symptoms are the same for so many things. If it wasn't for doctors we would be in a world of hurt.

[@somalimedicine9677]

Amazing vedio dr

[@Jen22w]

DRESS is also 'the gift' that keeps on giving. As if almost a full year on steroids and liver and thyroid damage wasn't enough, I'm STILL on high dose antihistamines a year and a half later. :( I'm lucky to live in a state and medical group known for excellence. Mass General Brigham!

[@ibrahimelguindy9484]

¹excellent presentation. Thanks.

[@MarcinGomulak]

I'm currently fighting the outcomes of the DRESS due to carbamazepine. I've been in hospital for three weeks. I was on a verge of actually dying. That was horrible. The syndrome attacked my lungs and heart too, but I recovered pretty fast. The steroids were the only meds that actually worked on me and stopped the never ending fever. Right now I'm all itchy, my skin is peeling off. It's month after the treatment, but I'm still fighting it. The showers make the skin burn. It's all awful. Anyway- the steroids worked, but I've already took them off as lectured by the doctor.

[@sunving]

Thank you very much. I wonder wether cloxacilin could induced DRESS , in Med search only case report.

[@xaaboopinkly]

Thanks for this great video sir! Is DRESS similar to serositis, which type of hypersensitivity reaction DRESS is?! It’s either type 3 or 4, I’m not sure..

[@merwitch]

I currently have this thanks to lamotrigine. I was officially diagnosed few weeks ago. The redness of the rash disappearing but the bumps are still there and it gets VERY itchy and painful at night. I can’t help but scratch and even if water comes in contact with my skin it burns. So obviously baths are painful. My dermatologist put me on steroids now I’m all out and I don’t know what to do but she seems like she’s not taking this seriously. And my employer still expects me to come into work.

[@dr.derbyallen7063]

Dr strong , with advent of new superspecialities of medicine such as cardiology, nephro, gastro etc. Etc. Do you feel it's wise to sustain a branch internal medicine or it should be erased ? Please share your views.

[@hdeezy492]

I believe I have this as I’ve always been healthy and have great skin. Then after a round of antibiotics my entire body broke out with lesions.

[@justjeanne1458]

Great info.! I was so sick all of 2019 with 9 different infections including 2 horrible rashes that looked like the one you showed in this presentation. 7 specialist couldn't determine why I was so sick. Can this happen when a Rx is withdrawn? My 1st rash appeared a couple of weeks after I stopped Xeljanx. The 2nd one appeared a few weeks after 2 loading dose infusions of Simponi Aria. Just curious. Thanks for these videos :).

[@StrongMed]

I can't offer specific, individualized medical advice, but DRESS is not triggered by the discontinuation of a medication. However, because there is a lag in the onset of symptoms, I can imagine the appearance of DRESS manifestations happening immediately after a new medication was stopped. For example, if a particular med was started on March 1, stopped on March 21 for a completely unrelated reason, and then a rash from DRESS became apparent on March 24. But also, the maculopapular rash that was shown in the video is very non-specific, and is indistinguishable by sight from that caused by other conditions. And while DRESS can be challenging to diagnose, I doubt that 7 different physicians would all have missed it.

[@aquickstory2196]

I currently have this rash

[@valentinemcdermott]

Some patients may be taking anticonvulsants, or glucocorticoids and other drugs that would otherwise be tapered before discontinuing them. Would you immediately discontinue those drugs if you suspected them as a cause of DRESS syndrome?

[@StrongMed]

Every patient's situation is different of course, but in general, the risk from DRESS exceeds the risk from abrupt medication cessation in most cases. This is especially true since DRESS usually manifests before a person's body would have developed physiologic reliance on the causative medications. There are also things that can be done to mitigate withdrawal risk. For example, if needing to stop carbamazepine (an aromatic anticonvulsant) in a patient with a seizure disorder, one would probably start a non-aromatic anticonvulsant (e.g. levetiracetam) at the same time.

[@mohammadal-drees3106]

I think I have DRESS. Funnily enough, my surname is Al-Drees. I’m allergic to *Paroxetine* (some of the generic brands, and I would throw up at times), *Salipax* (it gave me pustules, itching and a dermatitis), *Zoloft* (itching), *Pristiq* (itching), and *Valdoxan* (itch, and moderate-severe bronchitis). I really don’t know what to do at this stage. I’m tired of trying new medications to see if my body will react to them or not. I’m currently living on the highest dose of antihistamine (Telfast + Aerius) every 12 hours. My allergist said that there isn’t a lab test that can identify what I’m allergic to, we covered every test possible.

[@BMill88]

Can it be caused from Amanita muscaria 🍄 ?

[@belizejuliette7223]

Hi again, what about Fluoexitin? Elevanse (vyaanse)? My liver is now affected.

[@StrongMed]

Fluoxetine is among the *relatively* more common drugs implicated in DRESS. A quick literature search for Elevanse and DRESS didn't turn up anything (e.g. prior case reports), but any drug could theoretically cause the syndrome.

[@zuhairyassin505]

Dr.strong i have question is vomiting after IV contrast adminstration considered an allergic reaction or chemical irritation of the CTZ in the midbrain and is it possible for vomitus to progress to anaphylaxis or not. plz correct me if i'm wrong

[@StrongMed]

I can't give specific, individualized medical advice here, so if you have personal medical questions, I recommend speaking with your own physician. However, vomiting after the administration of IV contrast is generally considered to be a *physiologic* (non-immune mediated) reaction rather than an allergic one. Some experts label post-contrast nausea and vomiting as an anaphylactoid reaction, which means a clinical picture similar to anaphylaxis but with a different underlying mechanism (i.e. not caused by the release of IgE antibodies). As to whether a history of vomiting in response to IV contrast increases the risk of developing classic anaphylaxis (e.g. hypotension, bronchoconstriction), I have not personally heard of that, and a quick literature search didn't turn up anything that directly answers the question either way.

[@zuhairyassin505]

@@StrongMed Dr.strong i deeply appreciate your quick response i'm a medstudent i had this thought about the underlying pathophysiology which did not make sense then but now its clear i had my own doubt and it turned out to be logical thanks again

[@kunetail]

Can scarlet fever be considered as a differentiel diagnosis ?

[@StrongMed]

Sure. The diagnostic criteria for DRESS requires either eosinophilia or atypical lymphocytes seen on blood smear, neither of which will necessarily be present in scarlet fever. However, the rest of the most common features of the syndrome (e.g. diffuse rash, fever, lymphadenopathy) are seen in scarlet fever too.

[@adolfogonzalez1682]

Does amoxicillin cause this as well?

[@StrongMed]

In short, yes. Amoxicillin is considered a "low risk" drug for causing DRESS, but there are many cases reported in the medical literature.

[@belizejuliette7223]

Can this happen with drugs like Stilnoct, xanax?

[@StrongMed]

I don't want to say that it's literally impossible, but I did a quick literature search just now and did not find a single documented case of either medication causing DRESS.

[@belizejuliette7223]

Thank you