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Adjustment reaction with physical symptoms — Clinical Guidelines

Overview

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe, idiosyncratic drug-induced hypersensitivity syndrome characterized by fever, rash, lymphadenopathy, hematological abnormalities (eosinophilia), and multi-organ involvement 3 7.

Diagnosis

Key Diagnostic Criteria: Fever, rash, lymphadenopathy, hematological abnormalities (eosinophilia), and involvement of at least one internal organ 3 7.

Recommended Tests: Complete blood count (CBC) with differential, liver function tests, renal function tests, and specific organ function assessments based on clinical suspicion 3 7.

Grading: Severity grading systems exist but are not universally standardized; clinical presentation and organ involvement guide severity 7.

Management

First-Line Treatment: High-dose corticosteroids (e.g., prednisone 1-2 mg/kg/day) are the mainstay of treatment 7.

Adjunctive Therapies: Intravenous immunoglobulin (IVIG) may be considered in severe cases 7.

Discontinuation of Culprit Drug: Immediate discontinuation of the suspected drug is crucial 3 7.

Supportive Care: Management of organ dysfunction, fluid balance, and monitoring in ICU settings for severe cases 11 12.

Special Populations

Elderly: Increased risk of severe complications and multi-organ involvement; close monitoring and aggressive management are essential 15.

Comorbidities: Presence of comorbidities can exacerbate DRESS severity; individualized care plans are necessary 15.

Key Recommendations

Initiate high-dose corticosteroids promptly upon diagnosis to manage systemic inflammation and organ involvement (Evidence: Strong 7).

Discontinue the suspected drug immediately to halt progression of the reaction (Evidence: Strong 3 7).

Consider ICU admission for patients with severe manifestations including shock or multi-organ dysfunction (Evidence: Moderate 11 12).

Monitor for persistent or chronic manifestations, as DRESS can have prolonged courses with sequelae (Evidence: Moderate 3).

Evaluate for potential drug interactions, especially with antibiotics and other medications known to cause DRESS, through pharmacovigilance databases (Evidence: Moderate 1 2 6).

References

1 Goyal K, Sharma R, Datusalia AK, Khatik GL, Kumar A. Identification of novel signal of DRESS associated with antibiotics: a disproportionality analysis of the FDA adverse event reporting system (FAERS) database. European journal of clinical pharmacology 2026. link 2 de Camargo MB, Ribeiro-Vaz I, de Cássia Bergamaschi C, Silva MT. Antibiotics and Drug Reaction With Eosinophilia and Systemic Symptoms (DRESS) Syndrome: Analysis of Brazilian Pharmacovigilance Registries. Pharmacoepidemiology and drug safety 2025. link 3 Dezoteux F, Staumont-Salle D. DRESS (drug reaction with eosinophilia and systemic symptoms): a possible prolonged course with sequelae. European journal of dermatology : EJD 2024. link 4 de Filippis R, Kane JM, Arzenton E, Moretti U, Raschi E, Trifirò G et al.. Antipsychotic-Related DRESS Syndrome: Analysis of Individual Case Safety Reports of the WHO Pharmacovigilance Database. Drug safety 2024. link 5 Liang C, An P, Zhang Y, Liu X, Zhang B. Fatal outcome related to drug reaction with eosinophilia and systemic symptoms: a disproportionality analysis of FAERS database and a systematic review of cases. Frontiers in immunology 2024. link 6 Li W, Yu Y, Li M, Fang Q, Jin X, Lin H et al.. Identification of novel signal of proton pump inhibitor-associated drug reaction with eosinophilia and systemic symptoms: a disproportionality analysis. International journal of clinical pharmacy 2024. link 7 Ak T, Erdem S, Durmus RB, Kimyon U, Engin B, Bavunoglu I. How to recognize and manage challenging DRESS cases: Two case reports and a review of the literature. Dermatologic therapy 2022. link 8 Neha R, Beulah E, Anusha B, Vasista S, Stephy C, Subeesh V. Vemurafenib Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): A Disproportionality Analysis in FAERS Database. Current reviews in clinical and experimental pharmacology 2021. link 9 Cuestas D, Forero Y, Galvis I, Peñaranda E, Cortes C, Motta A et al.. Drug reaction with eosinophilia and systemic symptoms (DRESS) and multiple organ dysfunction syndrome (MODS): one more reason for a new effective treatment against leishmaniasis. International journal of dermatology 2018. link 10 Jakkidi M, Basmadjian C, Roy S. An illusion of septic shock: acute generalised exanthematous pustulosis with multiorgan dysfunction. BMJ case reports 2017. link 11 Kimmoun A, Dubois E, Perez P, Barbaud A, Levy B. Shock state: an unrecognized and underestimated presentation of drug reaction with eosinophilia and systemic symptoms. Shock (Augusta, Ga.) 2013. link 12 Kumar A, Goldfarb JW, Bittner EA. A case of drug rash with eosinophilia and systemic symptoms (DRESS) syndrome complicating airway management. Canadian journal of anaesthesia = Journal canadien d'anesthesie 2012. link 13 Daveluy A, Milpied B, Barbaud A, Lebrun-Vignes B, Gouraud A, Laroche ML et al.. Fluindione and drug reaction with eosinophilia and systemic symptoms: an unrecognised adverse effect?. European journal of clinical pharmacology 2012. link 14 Shaughnessy KK, Bouchard SM, Mohr MR, Herre JM, Salkey KS. Minocycline-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome with persistent myocarditis. Journal of the American Academy of Dermatology 2010. link 15 Eshki M, Allanore L, Musette P, Milpied B, Grange A, Guillaume JC et al.. Twelve-year analysis of severe cases of drug reaction with eosinophilia and systemic symptoms: a cause of unpredictable multiorgan failure. Archives of dermatology 2009. link 16 Baruzzi A, Contin M, Barbara G, Cremon C, De Giorgio R, Patrizi A et al.. Drug rash with eosinophilia and systemic symptoms secondary to phenobarbitone. Clinical neuropharmacology 2003. link 17 Schrodt BJ, Kulp-Shorten CL, Callen JP. Necrotizing vasculitis of the skin and uterine cervix associated with minocycline therapy for acne vulgaris. Southern medical journal 1999. link

Adjustment reaction with physical symptoms