Renal Manifestations of Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS) Syndrome: A Systematic Review of 71 Cases

Abstract

Unlike other adverse drug reactions, visceral organ involvement is a prominent feature of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome and correlates with mortality. The aim of this study was to systematically review cases published in PubMed-indexed, peer-reviewed journals in which patients had renal injury during the episode of DRESS syndrome (DS). We found 71 cases, of which 67 were adults and 56% were males. Female sex was associated with higher mortality. Chronic kidney disease (CKD) was present in 14% of patients who developed acute kidney injury (AKI) during DS. In 21% of cases, the kidneys were the only visceral organ involved, while 54% of patients had both liver and kidney involvement. Eosinophilia was absent in 24% of patients. The most common classes of medication associated with renal injury in DS were antibiotics in 34%, xanthine oxidase inhibitors in 15%, and anticonvulsants in 11%. Among antibiotics, vancomycin was the most common culprit in 68% of patients. AKI was the most common renal manifestation reported in 96% of cases, while isolated proteinuria or hematuria was present in only 4% of cases. In cases with AKI, 88% had isolated increase in creatinine and decrease in glomerular filtration (GFR), 27% had AKI concomitantly with proteinuria, 18% had oliguria, and 13% had concomitant AKI with hematuria. Anuria was the rarest manifestation, occurring in only 4% of patients with DS. Temporary renal replacement therapy was needed in 30% of cases, and all but one patient fully recovered renal function. Mortality of DS in this cohort was 13%, which is higher than previously reported. Medication class, latency period, or pre-existing CKD were not found to be associated with higher mortality. More research, particularly prospective studies, is needed to better recognize the risks associated with renal injury in patients with DS. The development of disease-specific biomarkers would also be useful so DS with renal involvement can be easier distinguished from other eosinophilic diseases that might affect the kidney.

Case Report: Minocycline-induced drug reaction with eosinophilia and systemic symptoms syndrome: a case report and literature review

“…The diagnostic criteria of DRESS syndrome include the suspicion of a drug-related reaction as well as the occurrence of acute rash, fever (>38°C), lymphadenopathy, hematologic abnormalities, and systemic involvement ( Martins et al, 2021 ). The systemic involvement of internal organs may manifest as hepatitis, nephrotoxicity, pneumonitis, cerebral edema, eosinophilia, pericardial effusion, leukocytosis, myocarditis, or thyroiditis ( Taweesedt et al, 2019 ; Radovanovic et al, 2022 ; Dagnon da Silva et al, 2023 ). In our case, the patient had pharyngitis, lymphadenopathy, AKI, hepatitis, and splenomegaly.…”

“…A recent systematic review summarized 71 cases with renal manifestations of DRESS syndrome showed that AKI was the most common manifestation in 96% of the patients. 27% had AKI with proteinuria and anuria was the rarest manifestation ( Dagnon da Silva et al, 2023 ). The mortality rate associated with DRESS syndrome is 10%–20% usually due to myocarditis or hepatotoxicity ( Heymann, 2020 ).…”

Pediatric drug reaction with eosinophilia and systemic symptoms: A 12‐year retrospective study in a tertiary center

“…Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare life‐threatening adverse drug reaction characterized by multiple organ involvement 1 including the liver, 2,3 lungs, 4 heart, 5 gastrointestinal system, 6 and kidneys 7–9 . DRESS presents with fever and skin rash, lymphadenopathy, internal organ involvement, and hematological alteration 10 .…”

DRESS Syndrome: Renal Involvement in Two Cases – A Comprehensive Analysis and Literature Review of Improved Diagnosis and Treatment

“…This can be determined by elevated serum creatinine (SCr) levels, decreased glomerular filtration rate (GFR), or hematuria, proteinuria, and eosinophiluria. [ 6 ] The differential diagnosis of DRESS syndrome includes other cutaneous adverse drug reactions, such as Stevens-Johnson syndrome/toxic epidermal, necrolysis autoimmune diseases, such as acute cutaneous lupus erythematosus, and lymphomas, hypereosinophilic syndromes, and viral infections. In the case of renal involvement, it is important to differentiate DRESS from drug-induced acute interstitial nephritis, which often manifests with the triad of rash, fever, and eosinophilia.…”

“…In the case of renal involvement, it is important to differentiate DRESS from drug-induced acute interstitial nephritis, which often manifests with the triad of rash, fever, and eosinophilia. DRESS is usually accompanied by involvement of other internal organs and features, such as lymphadenopathy and facial swelling, that are absent in interstitial nephritis [ 6 ]. The Registry of Severe Cutaneous Adverse Reactions (RegiSCAR) scoring system is used to confirm or exclude the diagnosis of DRESS [ 2 ].…”