metricas
covid
Buscar en
Annals of Hepatology
Toda la web
Inicio Annals of Hepatology Severe acute hepatitis in the dress syndrome: Report of two cases
Journal Information

Statistics

Follow this link to access the full text of the article

Severe acute hepatitis in the dress syndrome: Report of two cases
Sabela Lens*, Gonzalo Crespo*, Jose A. Carrión*, Rosa Miquel**, Miquel Navasa
,
Corresponding author
mnavasa@clinic.ub.es

Correspondence and reprint request:
* Liver Unit, Institut de Malalties Digestives (IMD), Hospital Clinic, Instituí d’lnvestigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CIBER de Enfermedades Hepáticas y Digestivas (CIBERehd), Barcelona, Spain
** Pathology Department, Hospital Clínic, IDIBAPS, CIBERehd, Barcelona, Spain
Read
1795
Times
was read the article
346
Total PDF
1449
Total HTML
Share statistics
 array:24 [
  "pii" => "S1665268119316631"
  "issn" => "16652681"
  "doi" => "10.1016/S1665-2681(19)31663-1"
  "estado" => "S300"
  "fechaPublicacion" => "2010-04-01"
  "aid" => "71349"
  "copyright" => "Fundación Clínica Médica Sur, A.C."
  "copyrightAnyo" => "2010"
  "documento" => "article"
  "crossmark" => 0
  "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
  "subdocumento" => "crp"
  "cita" => "Ann Hepatol. 2010;9:198-201"
  "abierto" => array:3 [
    "ES" => true
    "ES2" => true
    "LATM" => true
  ]
  "gratuito" => true
  "lecturas" => array:2 [
    "total" => 53
    "formatos" => array:3 [
      "EPUB" => 14
      "HTML" => 22
      "PDF" => 17
    ]
  ]
  "itemSiguiente" => array:19 [
    "pii" => "S1665268119316643"
    "issn" => "16652681"
    "doi" => "10.1016/S1665-2681(19)31664-3"
    "estado" => "S300"
    "fechaPublicacion" => "2010-04-01"
    "aid" => "71350"
    "copyright" => "Fundación Clínica Médica Sur, A.C."
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "crp"
    "cita" => "Ann Hepatol. 2010;9:202-6"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 88
      "formatos" => array:3 [
        "EPUB" => 29
        "HTML" => 28
        "PDF" => 31
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "titulo" => "Spontaneous clearance of hepatitis C infection post-liver transplant: A rare but real phenomenon? A case report and review of the literature"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "202"
          "paginaFinal" => "206"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Maznar Haque, Almoutaz Hashim, Erica D. Greanya, Urs P. Steinbrecher, Siegfried R. Erb, Eric M. Yoshida"
          "autores" => array:6 [
            0 => array:2 [
              "nombre" => "Maznar"
              "apellidos" => "Haque"
            ]
            1 => array:2 [
              "nombre" => "Almoutaz"
              "apellidos" => "Hashim"
            ]
            2 => array:2 [
              "nombre" => "Erica D."
              "apellidos" => "Greanya"
            ]
            3 => array:2 [
              "nombre" => "Urs P."
              "apellidos" => "Steinbrecher"
            ]
            4 => array:2 [
              "nombre" => "Siegfried R."
              "apellidos" => "Erb"
            ]
            5 => array:2 [
              "nombre" => "Eric M."
              "apellidos" => "Yoshida"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119316643?idApp=UINPBA00004N"
    "url" => "/16652681/0000000900000002/v1_201907070740/S1665268119316643/v1_201907070740/en/main.assets"
  ]
  "itemAnterior" => array:19 [
    "pii" => "S166526811931662X"
    "issn" => "16652681"
    "doi" => "10.1016/S1665-2681(19)31662-X"
    "estado" => "S300"
    "fechaPublicacion" => "2010-04-01"
    "aid" => "71348"
    "copyright" => "Fundación Clínica Médica Sur, A.C."
    "documento" => "article"
    "crossmark" => 0
    "licencia" => "http://creativecommons.org/licenses/by-nc-nd/4.0/"
    "subdocumento" => "crp"
    "cita" => "Ann Hepatol. 2010;9:194-7"
    "abierto" => array:3 [
      "ES" => true
      "ES2" => true
      "LATM" => true
    ]
    "gratuito" => true
    "lecturas" => array:2 [
      "total" => 44
      "formatos" => array:3 [
        "EPUB" => 5
        "HTML" => 14
        "PDF" => 25
      ]
    ]
    "en" => array:10 [
      "idiomaDefecto" => true
      "titulo" => "Spontaneous HBsAg seroconversion after severe flare of chronic hepatitis B infection"
      "tienePdf" => "en"
      "tieneTextoCompleto" => "en"
      "tieneResumen" => "en"
      "paginas" => array:1 [
        0 => array:2 [
          "paginaInicial" => "194"
          "paginaFinal" => "197"
        ]
      ]
      "contieneResumen" => array:1 [
        "en" => true
      ]
      "contieneTextoCompleto" => array:1 [
        "en" => true
      ]
      "contienePdf" => array:1 [
        "en" => true
      ]
      "autores" => array:1 [
        0 => array:2 [
          "autoresLista" => "Akif Altinbaş, llhami Yüksel, Melih Pamukcu, Fuat Ekiz, Ömer Başar, Osman Yüksel"
          "autores" => array:6 [
            0 => array:3 [
              "preGrado" => "M.D."
              "nombre" => "Akif"
              "apellidos" => "Altinbaş"
            ]
            1 => array:2 [
              "nombre" => "llhami"
              "apellidos" => "Yüksel"
            ]
            2 => array:2 [
              "nombre" => "Melih"
              "apellidos" => "Pamukcu"
            ]
            3 => array:2 [
              "nombre" => "Fuat"
              "apellidos" => "Ekiz"
            ]
            4 => array:2 [
              "nombre" => "Ömer"
              "apellidos" => "Başar"
            ]
            5 => array:2 [
              "nombre" => "Osman"
              "apellidos" => "Yüksel"
            ]
          ]
        ]
      ]
    ]
    "idiomaDefecto" => "en"
    "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S166526811931662X?idApp=UINPBA00004N"
    "url" => "/16652681/0000000900000002/v1_201907070740/S166526811931662X/v1_201907070740/en/main.assets"
  ]
  "en" => array:15 [
    "idiomaDefecto" => true
    "titulo" => "Severe acute hepatitis in the dress syndrome: Report of two cases"
    "tieneTextoCompleto" => true
    "paginas" => array:1 [
      0 => array:2 [
        "paginaInicial" => "198"
        "paginaFinal" => "201"
      ]
    ]
    "autores" => array:1 [
      0 => array:4 [
        "autoresLista" => "Sabela Lens, Gonzalo Crespo, Jose A. Carrión, Rosa Miquel, Miquel Navasa"
        "autores" => array:5 [
          0 => array:3 [
            "nombre" => "Sabela"
            "apellidos" => "Lens"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          1 => array:3 [
            "nombre" => "Gonzalo"
            "apellidos" => "Crespo"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          2 => array:3 [
            "nombre" => "Jose A&#46;"
            "apellidos" => "Carri&#243;n"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
            ]
          ]
          3 => array:3 [
            "nombre" => "Rosa"
            "apellidos" => "Miquel"
            "referencia" => array:1 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;&#42;</span>"
                "identificador" => "aff2"
              ]
            ]
          ]
          4 => array:4 [
            "nombre" => "Miquel"
            "apellidos" => "Navasa"
            "email" => array:1 [
              0 => "mnavasa@clinic.ub.es"
            ]
            "referencia" => array:2 [
              0 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "aff1"
              ]
              1 => array:2 [
                "etiqueta" => "<span class="elsevierStyleSup">&#42;</span>"
                "identificador" => "cor1"
              ]
            ]
          ]
        ]
        "afiliaciones" => array:2 [
          0 => array:3 [
            "entidad" => "Liver Unit&#44; Institut de Malalties Digestives &#40;IMD&#41;&#44; Hospital Clinic&#44; Institu&#237; d&#8217;lnvestigacions Biom&#232;diques August Pi i Sunyer &#40;IDIBAPS&#41;&#44; CIBER de Enfermedades Hep&#225;ticas y Digestivas &#40;CIBERehd&#41;&#44; Barcelona&#44; Spain"
            "etiqueta" => "&#42;"
            "identificador" => "aff1"
          ]
          1 => array:3 [
            "entidad" => "Pathology Department&#44; Hospital Cl&#237;nic&#44; IDIBAPS&#44; CIBERehd&#44; Barcelona&#44; Spain"
            "etiqueta" => "&#42;&#42;"
            "identificador" => "aff2"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor1"
            "etiqueta" => "&#42;"
            "correspondencia" => "Correspondence and reprint request&#58;"
          ]
        ]
      ]
    ]
    "resumenGrafico" => array:2 [
      "original" => 0
      "multimedia" => array:7 [
        "identificador" => "f0005"
        "etiqueta" => "Figure 1A"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 884
            "Ancho" => 2072
            "Tamanyo" => 297925
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Generalised maculopapular rash affecting the arm&#46; <span class="elsevierStyleBold">B&#46;</span> HE staining&#46; Acute hepatitis&#46; Marked lobular disarray and multiple necroinflammatory foci are seen through the hepatic parenchyma&#46; The inflammatory infiltrate is lymphoplasmacytic&#44; including clusters of eosinophils as easily seen around the small portal tract seen at the center of the picture&#46;</p>"
        ]
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Case Report 1</span><p id="p0005" class="elsevierStylePara elsevierViewall">A 29-year-old caucassian woman was admitted to our Liver Unit with ten days history of high fever&#44; generalized maculopapular rash &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1A</a>&#41; and jaundice&#46; On physical examination she presented es-plenomegalia&#44; peripheral lymph node enlargement&#44; bilateral pleural effusion and ascites&#46; She had a history of seronegative polyarthritis treated with oral methotrexate&#44; which had been replaced by salazo-pyrine 8 weeks before her hospital admission&#46; She denied illicit drug use or alcohol abuse&#44; recent travels or blood transfusion&#46; Blood tests showed a marked impairment in liver function &#40;AST 1319 IU&#47;L&#44; ALT 1117 IU&#47;L&#44; AP 1171 UI&#47;L&#44; total bilirubin 13&#46;5 mg&#47;dL &#40;direct 10 mg&#47;dL&#41;&#44; INR 3&#46;18 and eosinophilia &#40;2388 cells&#47;mm<span class="elsevierStyleSup">3</span>&#44; normal &#60; 500&#41;&#46; Serological tests for HAV&#44; HBV&#44; HCV&#44; EBV&#44; CMV&#44; HSV&#44; VZV&#44; HIV and syphillis were negative&#46; In contrast&#44; IgG and PCR for HHV-6 was positive&#46; Blood&#44; urine and ascitic fluid cultures for bacteria were negative&#46; Autoimmu-nity studies &#40;ANA&#44; AMA&#44; Anti LKM&#41; and plasma ceruloplasmin level were normal&#46; Abdominal ultrasound did not detect biliary dilatation or liver masses&#46; A transjugular liver biopsy was performed to clarify the diagnosis and exclude malignancy&#46; The histology revealed important centrolobular necrosis and dense portal and lobular inflammatory infiltrates containing lymphocytes and eosinophils &#40;<a class="elsevierStyleCrossRef" href="#f0005">Figure 1B</a>&#41;&#44; in keeping with the diagnosis of drug-induced hepatitis&#46; Salazopyrine was stopped at admission and oral corticoid therapy was started on the third day at a dose of 60 mg&#47;day &#40;1 mg&#47;kg of weight&#41; due to the suspicion of DRESS&#46; There was no response in the following two days with worsening of the general condition and signs of liver failure in biological tests&#44; with transaminases over 2&#44;500 IU&#47;L&#44; total bilirubin 18 mg&#47;dL and INR 3&#46;18&#46; Clinical signs of hepatic encephalopathy were absent&#46; Intravenous methylprednisolone was increased up to 1 g&#47;24 h during three more days and then slowly tapered&#46; The skin lesions progressively improved within the next week&#44; as did the eosinophilia and liver function reaching normal values after 21 days and during the 12-month-follow up&#46;</p><elsevierMultimedia ident="f0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Case Report 2</span><p id="p0010" class="elsevierStylePara elsevierViewall">An 18-year-old Hispanic woman was admitted to the hospital due to a week duration of high fever with a morbilliform macular rash affecting the palms&#44; facial edema and pharyngeal purulent plaques&#46; There were no lymphadenopathies or splenomegaly on physical examination&#46; She had a history of epilepsy treated with valproic acid and levetiracetam had been added 3 weeks before hospital admission because of a relapse of her epilepsy&#46; She denied illicit drug use or alcohol abuse&#44; recent travels or blood transfusions&#46; Blood tests showed 810 eosino-phils&#47;mm<span class="elsevierStyleSup">3</span> which increased up to 4700&#47;mm<span class="elsevierStyleSup">3</span> on day 7 and liver dysfunction&#58; AST&#47;ALT 60&#47;178 IU&#47;L&#44; AP 1209 UI&#47;L&#44; total bilirubin 1&#46;8 mg&#47;dL &#40;direct 0&#46;9 mg&#47; dL&#41; and INR 1&#46;25&#46; After 24 hours&#44; she complained of respiratory distress&#46; A chest X-ray showed a bilateral interstitial infiltrate&#44; and arterial blood gas analysis displayed hypoxemia and normocapnia&#46; Se-rological tests for HAV&#44; HBV&#44; HCV&#44; CMV&#44; HSV&#44; EBV&#44; HIV and HH6-V were negative&#44; while PCR for HHV-6 was positive&#46; Urine and blood cultures were negative for bacteria&#46; Autoimmunity studies &#40;ANA&#44; AMA&#44; Anti LKM&#41; and plasma ceruloplasmin level were normal&#46; Abdominal ultrasound was normal&#46; Skin biopsies showed an inflammatory infiltrate composed predominantly of lymphocytes and endo-thelial tumefaction&#46; Levetiracetam was discontinued at admission and valproic acid was continued as an-ticonvulsant&#46; Intravenous methylprednisolone was started at 90 mg&#47;day &#40;patient&#8217;s weight 50 Kg&#41; and rapidly tapered over four days&#46; She presented a relapse of respiratory symptoms&#44; grade II hepatic ence-phalopathy and progressive worsening of liver tests &#40;AST&#47;ALT 1145&#47;1357 IU&#47;L&#44; total bilirubin 5&#46;4 mg&#47;dL and INR 3&#46;03&#41;&#46; At this point a transjugular liver biopsy was performed due to the high suspicion of</p><p id="p0015" class="elsevierStylePara elsevierViewall">DRESS demonstrating the presence of confluent necrosis&#44; Councilman bodies and an inflammatory infiltrate with a marked increase of eosinophils&#46; Intravenous corticosteroid therapy was resumed with clinical and analytical improvement within the following days&#46; During a 3-month follow-up&#44; the dosage of corticosteroids was gradually tapered and stopped&#44; and the patient remains well with normal liver tests 9 months after the episode&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="p0020" class="elsevierStylePara elsevierViewall">Drug induced liver injury &#40;DILI&#41; is a common cause of hepatitis and acute liver failure&#46; Diagnosis of hepatotoxicity remains difficult because of the lack of specific clinical and biochemical markers and sometimes relies on exclusion of other causes of liver in-jury&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In this setting&#44; several clinical indexes have been developed in order to evaluate causality in drug adverse events&#46; Regarding our cases&#44; we assessed the probability of a hepatotoxic adverse drug reaction with the CIOMS&#47;RUCAM scale&#44; achieving a definite causality in both of our cases &#40;score &#62; 8 points&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="p0025" class="elsevierStylePara elsevierViewall">When hepatotoxicity is mediated by an allergic mechanism it can be accompanied by systemic manifestations&#46; Bocquet&#44; <span class="elsevierStyleItalic">et al&#46;</span> established the term DRESS in 1996<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> to describe a hypersensitivity syndrome presenting with fever&#44; skin rash and multi-organic involvement in the first 8 weeks after the initiation of a new drug&#46; Diagnostic criteria include the simultaneous presence of three conditions&#58;<ul class="elsevierStyleList" id="li0005"><li class="elsevierStyleListItem" id="list0005"><span class="elsevierStyleLabel">1&#46;</span><p id="p0030" class="elsevierStylePara elsevierViewall">Drug-induced skin eruption&#46;</p></li><li class="elsevierStyleListItem" id="list0010"><span class="elsevierStyleLabel">2&#46;</span><p id="p0035" class="elsevierStylePara elsevierViewall">Eosinophil &#62; 1&#44;500&#47;L&#46;</p></li><li class="elsevierStyleListItem" id="list0015"><span class="elsevierStyleLabel">3&#46;</span><p id="p0040" class="elsevierStylePara elsevierViewall">At least one of the following systemic abnormalities&#58; enlarged lymph nodes&#44; hepatitis &#40;transaminases &#62; 2N&#41;&#44; interstitial nephropathy&#44; interstitial lung disease or myocardial involvement&#46; Mortality in this syndrome&#44; due to liver&#44; kidney and heart failure&#44; may be as high as 107&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p></li></ul></p><p id="p0045" class="elsevierStylePara elsevierViewall">A large number of drugs have been described as inducers of the condition&#44; the most common being sulfasalazine&#44; carbamazepine&#44; phenobarbital&#44; allopu-rinol&#44; and some antibiotics such as vancomicyn and minocycline&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="p0050" class="elsevierStylePara elsevierViewall">The pathophysiology of the syndrome is unclear&#46; It has been suggested that certain drugs may cause hypersensitivity as a result of abnormalities in the production and detoxification of its active metabolites in patients with pharmacogenetic or acquired variations in drug metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The hypersensitivity reaction is associated with high levels of IL-5 and eosinophil accumulation<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> and may justify the use of steroids in this syndrome&#46; In addition&#44; as shown in the two cases presented and reported in others&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> the strong association between DRESS and HHV-6 reactivation points to a complex interaction among virus&#44; antiviral immunity and drug-specific immune responses&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> This association seems to be disease-specific&#44; as other drug reactions are not related to HHV-6 reactivation&#44; and has led some investigators to propose the term <span class="elsevierStyleItalic">drug-induced hypersensitivity syndrome</span> &#40;DIHS&#41;&#44; highlighting the importance of HHV-6 reactivation in their diagnostic criteria&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> Nevertheless&#44; a recent report<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> suggests that certain drugs may stimulate a massive expansion of drug specific cytotoxic T cells that destroy hepatocytes via a cell-contact-dependent mechanism&#46;</p><p id="p0055" class="elsevierStylePara elsevierViewall">Liver involvement in DRESS&#47;DIHS is common and may range from a transitory increase in liver enzymes to liver necrosis with fulminant hepatic failure&#46; Histological features are those of a drug-induced acute hepatitis&#58; centrolobular necrosis and dense inflammatory infiltrates containing lymphocytes and eosinophils&#46; Most reports in the literature describe cases of mild hepatitis&#44;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> but acute liver failure resulting in death or liver transplantation can also occur&#46; Even though the cases of DRESS presenting with severe acute hepatitis &#40;defined as ALT levels 10xULN and&#47;or acute liver failure&#44; <span class="elsevierStyleItalic">ie&#46;</span> coagulopathy and&#47;or encephalopathy&#41; reported in the literature<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">-</span><a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> are scarce&#44; they seem to be more frequent in women between the second and fourth decade of life and they have been mostly related to the use of sulfasalazine&#46; Approximately fifty per cent of the reported cases resulted in death or liver transplantation&#44; and apparently the outcome was independent of the use or dose of immunosuppressive therapy&#46; The use of corticosteroids is usually recommended in cases of drug induced hepatitis with allergic features such as DRESS&#44; specially with life-threatening visceral manifestations not responding to withdrawal of the responsible drug&#44; although scientific basis of this recommendation is lacking and the ideal dosage and length of therapy&#44; if required&#44; are unknown&#46; <a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Interestingly&#44; our two cases presented a relapse of symptoms after initial tapering of medication which required resuming high dose corticosteroids to control the disease&#46; Thus&#44; our limited experience would suggest that high doses of systemic steroids may be helpful and that tapering should be performed slowly during follow-up&#46;</p><p id="p0060" class="elsevierStylePara elsevierViewall">OLT has also been used in cases of acute liver failure in this setting&#46; Although long-term outcomes are unknown due to the absence of follow-up of the reported cases&#44; a recent article<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> warns about the possibility that the condition can recur after liver transplantation despite withdrawing the precipitating drug and potent immunosuppression&#46;</p><p id="p0065" class="elsevierStylePara elsevierViewall">In summary&#44; physicians providing care to liver patients should be aware of this entity&#44; as it can mimic other pathologies and is potentially life-threatening&#46; Prompt withdrawal of the incriminating drug is crucial as well as avoiding re-exposure to drugs known to cause the syndrome&#46; All cases of the DRESS syndrome should be reported to local phar-macosurveillance centers&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Abbreviations</span><p id="p0070" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="li0010"><li class="elsevierStyleListItem" id="list0020"><span class="elsevierStyleLabel">&#8226;</span><p id="p0075" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">DRESS&#58;</span> Drug rash&#44; eosinophilia and systemic symptoms&#46;</p></li><li class="elsevierStyleListItem" id="list0025"><span class="elsevierStyleLabel">&#8226;</span><p id="p0080" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">DIHS&#58;</span> Drug-induced hypersensitivity syndrome&#46;</p></li><li class="elsevierStyleListItem" id="list0030"><span class="elsevierStyleLabel">&#8226;</span><p id="p0085" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">AST&#58;</span> Aspartate aminotransferase&#46;</p></li><li class="elsevierStyleListItem" id="list0035"><span class="elsevierStyleLabel">&#8226;</span><p id="p0090" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ALT&#58;</span> Alanine aminotransferase&#46;</p></li><li class="elsevierStyleListItem" id="list0040"><span class="elsevierStyleLabel">&#8226;</span><p id="p0095" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">INR&#58;</span> Index Normalized Ratio&#46;</p></li><li class="elsevierStyleListItem" id="list0045"><span class="elsevierStyleLabel">&#8226;</span><p id="p0100" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HAV&#58;</span> Hepatitis A virus&#46;</p></li><li class="elsevierStyleListItem" id="list0050"><span class="elsevierStyleLabel">&#8226;</span><p id="p0105" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HBV&#58;</span> Hepatitis B virus&#46;</p></li><li class="elsevierStyleListItem" id="list0055"><span class="elsevierStyleLabel">&#8226;</span><p id="p0110" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HCV&#58;</span> Hepatitis C virus&#46;</p></li><li class="elsevierStyleListItem" id="list0060"><span class="elsevierStyleLabel">&#8226;</span><p id="p0115" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">EBV&#58;</span> Ebstein-Barr virus&#46;</p></li><li class="elsevierStyleListItem" id="list0065"><span class="elsevierStyleLabel">&#8226;</span><p id="p0120" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">VZV&#58;</span> Varicella zoster virus&#46;</p></li><li class="elsevierStyleListItem" id="list0070"><span class="elsevierStyleLabel">&#8226;</span><p id="p0125" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HIV&#58;</span> Human immunodeficiency virus&#46;</p></li><li class="elsevierStyleListItem" id="list0075"><span class="elsevierStyleLabel">&#8226;</span><p id="p0130" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">PCR&#58;</span> Polymerase chain reaction&#46;</p></li><li class="elsevierStyleListItem" id="list0080"><span class="elsevierStyleLabel">&#8226;</span><p id="p0135" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HHV-6&#58;</span> Human herpes virus 6&#46;</p></li><li class="elsevierStyleListItem" id="list0085"><span class="elsevierStyleLabel">&#8226;</span><p id="p0140" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">CMV&#58;</span> Cytomegalovirus&#46;</p></li><li class="elsevierStyleListItem" id="list0090"><span class="elsevierStyleLabel">&#8226;</span><p id="p0145" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">ANA&#58;</span> Antinuclear antibodies&#46;</p></li><li class="elsevierStyleListItem" id="list0095"><span class="elsevierStyleLabel">&#8226;</span><p id="p0150" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">AMA&#58;</span> Antimitocondrial antibodies&#46;</p></li><li class="elsevierStyleListItem" id="list0100"><span class="elsevierStyleLabel">&#8226;</span><p id="p0155" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Anti LKM&#58;</span> Anti liver-kidney microsomal antibodies&#46;</p></li><li class="elsevierStyleListItem" id="list0105"><span class="elsevierStyleLabel">&#8226;</span><p id="p0160" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">AP&#58;</span> Alkaline phosphatase&#46;</p></li><li class="elsevierStyleListItem" id="list0110"><span class="elsevierStyleLabel">&#8226;</span><p id="p0165" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">HSV&#58;</span> Herpes simple visrus&#46;</p></li></ul></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Financial Support</span><p id="p0170" class="elsevierStylePara elsevierViewall">Gonzalo Crespo was granted by Hospital Clinic &#40;Ajut a la Recerca Josep Font&#41; and Fundaci&#243;n BBVA&#46;</p></span></span>"
    "textoCompletoSecciones" => array:1 [
      "secciones" => array:8 [
        0 => array:3 [
          "identificador" => "xres1217536"
          "titulo" => "Abstract"
          "secciones" => array:1 [
            0 => array:1 [
              "identificador" => "abs0005"
            ]
          ]
        ]
        1 => array:2 [
          "identificador" => "xpalclavsec1132917"
          "titulo" => "Key words"
        ]
        2 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "Case Report 1"
        ]
        3 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Case Report 2"
        ]
        4 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Discussion"
        ]
        5 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "Abbreviations"
        ]
        6 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "Financial Support"
        ]
        7 => array:1 [
          "titulo" => "Reference"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Key words"
          "identificador" => "xpalclavsec1132917"
          "palabras" => array:2 [
            0 => "DRESS syndrome"
            1 => "Severe acute hepatitis"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abs0005" class="elsevierStyleSection elsevierViewall"><p id="sp0010" class="elsevierStyleSimplePara elsevierViewall">The DRESS <span class="elsevierStyleItalic">&#40;drug rash&#44; eosinophilia and systemic symptoms&#41;</span> syndrome&#44; also known as DIHS <span class="elsevierStyleItalic">&#40;drug-induced hypersensitivity syndrome&#41;&#44;</span> is a severe idiosyncratic reaction to several drugs&#44; mainly antiepileptics and antibiotics&#44; which can occasionally produce acute liver failure&#46; In this article we present two cases of the DRESS syndrome presenting with severe acute hepatitis&#44; including the first case of DRESS associated with levetiracetam&#46; Although both cases finally resolved with good outcomes&#44; DRESS can lead to acute liver failure and has a bad prognosis when liver damage is present&#46; Rapid diagnosis is crucial since withdrawal of the offending drug is the key of treatment&#44; while the potential role of corticosteroids is discussed&#46;</p></span>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:7 [
        "identificador" => "f0005"
        "etiqueta" => "Figure 1A"
        "tipo" => "MULTIMEDIAFIGURA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "figura" => array:1 [
          0 => array:4 [
            "imagen" => "gr1.jpeg"
            "Alto" => 884
            "Ancho" => 2072
            "Tamanyo" => 297925
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="sp0005" class="elsevierStyleSimplePara elsevierViewall">Generalised maculopapular rash affecting the arm&#46; <span class="elsevierStyleBold">B&#46;</span> HE staining&#46; Acute hepatitis&#46; Marked lobular disarray and multiple necroinflammatory foci are seen through the hepatic parenchyma&#46; The inflammatory infiltrate is lymphoplasmacytic&#44; including clusters of eosinophils as easily seen around the small portal tract seen at the center of the picture&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "Reference"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bs0005"
          "bibliografiaReferencia" => array:18 [
            0 => array:3 [
              "identificador" => "bib0005"
              "etiqueta" => "1&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Diagnosis&#44; management and prevention of drug-induced liver injury"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Verma S&#46;"
                            1 => "Kaplowitz N&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1136/gut.2008.163675"
                      "Revista" => array:6 [
                        "tituloSerie" => "Gut"
                        "fecha" => "2009"
                        "volumen" => "58"
                        "paginaInicial" => "1555"
                        "paginaFinal" => "1564"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19834119"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Assessment of drug-induced liver injury in clinical practice"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Lucena M&#46;I&#46;"
                            1 => "Garc&#237;a-Cort&#233;s M&#46;"
                            2 => "Cueto R&#46;"
                            3 => "Lopez-Duran J&#46;L&#46;"
                            4 => "Andrade R&#46;J&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1472-8206.2008.00566.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Fundam Clin Pharmacol"
                        "fecha" => "2008"
                        "volumen" => "22"
                        "paginaInicial" => "141"
                        "paginaFinal" => "158"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18353109"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0015"
              "etiqueta" => "3&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug-induced pseudolymphoma and drug hypersensitivity syndrome &#40;Drug Rash with Eosinophilia and Systemic Symptoms&#58; DRESS&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Bocquet H&#46;"
                            1 => "Bagot M&#46;"
                            2 => "Roujeau J&#46;C&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Semin Cutan Med Surg"
                        "fecha" => "1996"
                        "volumen" => "1"
                        "paginaInicial" => "250"
                        "paginaFinal" => "257"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0020"
              "etiqueta" => "4&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug-induced hypersensitivity syndrome &#40;DIHS&#41;&#58; a reaction induced by a complex interplay among herpesviruses and antiviral and antidrug immune responses"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Shiohara T&#46;"
                            1 => "Inaoka M&#46;"
                            2 => "Kano Y&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.2332/allergolint.55.1"
                      "Revista" => array:6 [
                        "tituloSerie" => "Allergol Int"
                        "fecha" => "2006"
                        "volumen" => "55"
                        "paginaInicial" => "1"
                        "paginaFinal" => "8"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17075280"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0025"
              "etiqueta" => "5&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Drug-induced hypersensitivity syndrome&#58; clinical and biologic disease patterns in 24 patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Ben m&#8217;rad M&#46;"
                            1 => "Leclerc-Mercier S&#46;"
                            2 => "Blanche P&#46;"
                            3 => "Franck N&#46;"
                            4 => "Rozenberg F&#46;"
                            5 => "Fulla Y&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Medicine &#40;Baltimore&#41;"
                        "fecha" => "2009"
                        "volumen" => "88"
                        "paginaInicial" => "131"
                        "paginaFinal" => "140"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0030"
              "etiqueta" => "6&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "DRESS syndrome in a patient on sulfasalazine for rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "Michel F&#46;"
                            1 => "Navellou J&#46;C&#46;"
                            2 => "Ferraud D&#46;"
                            3 => "Toussirot E&#46;"
                            4 => "Wendling D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jbspin.2004.06.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Joint Bone Spine"
                        "fecha" => "2005"
                        "volumen" => "72"
                        "paginaInicial" => "82"
                        "paginaFinal" => "85"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15681256"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0035"
              "etiqueta" => "7&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Management of drug rash with eosinophilia and systemic symptoms &#40;DRESS syndrome&#41;&#58; an update"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Tas S&#46;"
                            1 => "Simonart T&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1159/000069956"
                      "Revista" => array:6 [
                        "tituloSerie" => "Dermatology"
                        "fecha" => "2003"
                        "volumen" => "206"
                        "paginaInicial" => "353"
                        "paginaFinal" => "356"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12771485"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0040"
              "etiqueta" => "8&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Association of human herpesvirus 6 reactivation with the flaring and severity of drug-induced hypersensitivity syndrome"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Tohyama M&#46;"
                            1 => "Hashimoto K&#46;"
                            2 => "Yasukawa M&#46;"
                            3 => "Kimura H&#46;"
                            4 => "Horikawa T&#46;"
                            5 => "Nakajima K&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.08167.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2007"
                        "volumen" => "157"
                        "paginaInicial" => "934"
                        "paginaFinal" => "940"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17854362"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0045"
              "etiqueta" => "9&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "DRESS syndrome associated with HHV-6 reactivation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "Ichiche M&#46;"
                            1 => "Kiesch N&#46;"
                            2 => "De Bels D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejim.2003.09.004"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Intern Med"
                        "fecha" => "2003"
                        "volumen" => "14"
                        "paginaInicial" => "498"
                        "paginaFinal" => "500"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/14962704"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0050"
              "etiqueta" => "10&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The variable clinical picture of druginduced hypersensitivity syndrome&#47;drug rash with eosinophilia and systemic symptoms in relation to the eliciting drug"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Kano Y&#46;"
                            1 => "Shiohara T&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.iac.2009.04.007"
                      "Revista" => array:6 [
                        "tituloSerie" => "Immunol Allergy Clin North Am"
                        "fecha" => "2009"
                        "volumen" => "29"
                        "paginaInicial" => "481"
                        "paginaFinal" => "501"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19563993"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0055"
              "etiqueta" => "11&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The diagnosis of a DRESS syndrome has been sufficiently established on the basis of typical clinical features and viral reactivations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:3 [
                            0 => "Shiohara T&#46;"
                            1 => "Iijima M&#46;"
                            2 => "Ikezawa Z&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-2133.2007.07807.x"
                      "Revista" => array:7 [
                        "tituloSerie" => "Br J Dermatol"
                        "fecha" => "2007"
                        "volumen" => "156"
                        "numero" => "5"
                        "paginaInicial" => "1083"
                        "paginaFinal" => "1084"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17381452"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0060"
              "etiqueta" => "12&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Fulminant liver failure after vancomycin in a sulfasalazine-induced DRESS syndrome&#58; fatal recurrence after liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Mennicke M&#46;"
                            1 => "Zawodniak A&#46;"
                            2 => "Keller M&#46;"
                            3 => "Wilkens L&#46;"
                            4 => "Yawalkar N&#46;"
                            5 => "Stickel F&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1600-6143.2009.02788.x"
                      "Revista" => array:6 [
                        "tituloSerie" => "Am J Transplant"
                        "fecha" => "2009"
                        "volumen" => "9"
                        "paginaInicial" => "2197"
                        "paginaFinal" => "2202"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19706026"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            12 => array:3 [
              "identificador" => "bib0065"
              "etiqueta" => "13&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Carbamazepine-induced drug reaction with eosinophilia and systemic symptoms &#40;DRESS&#41; syndrome&#58; report of four cases and brief review"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Ganeva M&#46;"
                            1 => "Gancheva T&#46;"
                            2 => "Lazarova R&#46;"
                            3 => "Troeva J&#46;"
                            4 => "Baldaranov I&#46;"
                            5 => "Vassilev I&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1111/j.1365-4632.2008.03637.x"
                      "Revista" => array:7 [
                        "tituloSerie" => "Int J Dermatol"
                        "fecha" => "2008"
                        "volumen" => "47"
                        "numero" => "8"
                        "paginaInicial" => "853"
                        "paginaFinal" => "860"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18717872"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            13 => array:3 [
              "identificador" => "bib0070"
              "etiqueta" => "14&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "DRESS syndrome induced by sulphasalazine in rheumatoid arthritis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:7 [
                            0 => "Bejia I&#46;"
                            1 => "Hammouda S&#46;B&#46;"
                            2 => "Riahi K&#46;"
                            3 => "Zinelabidine F&#46;"
                            4 => "Mediouni B&#46;"
                            5 => "Touzi M&#46;"
                            6 => "Bergaoui N&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jbspin.2006.01.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Joint Bone Spine"
                        "fecha" => "2006"
                        "volumen" => "73"
                        "paginaInicial" => "764"
                        "paginaFinal" => "765"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16626997"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            14 => array:3 [
              "identificador" => "bib0075"
              "etiqueta" => "15&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Favourable issue of a fulminant hepatitis associated with sulfasalazine DRESS syndrome without liver transplantation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Descloux E&#46;"
                            1 => "Argaud L&#46;"
                            2 => "Dumortier J&#46;"
                            3 => "Scoazec J&#46;Y&#46;"
                            4 => "Boillot O&#46;"
                            5 => "Robert D&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00134-005-2846-3"
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2005"
                        "volumen" => "31"
                        "paginaInicial" => "1727"
                        "paginaFinal" => "1728"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/16283166"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            15 => array:3 [
              "identificador" => "bib0080"
              "etiqueta" => "16&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sulfasalazine-induced DRESS syndrome &#40;drug rash with eosinophilia and systemic symptoms&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "Aquino R&#46;T&#46;"
                            1 => "Vergueiro C&#46;S&#46;"
                            2 => "Magliari M&#46;E&#46;"
                            3 => "de Freitas T&#46;H&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Sao Paulo Med J"
                        "fecha" => "2008"
                        "volumen" => "126"
                        "paginaInicial" => "225"
                        "paginaFinal" => "226"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18853032"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            16 => array:3 [
              "identificador" => "bib0085"
              "etiqueta" => "17&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Dress syndrome and fulminant hepatic failure induced by lamotrigine"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "Amante M&#46;F&#46;"
                            1 => "Filippini A&#46;V&#46;"
                            2 => "Cejas N&#46;"
                            3 => "Lendoire J&#46;"
                            4 => "Imventarza O&#46;"
                            5 => "Parisi C&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Hepatol"
                        "fecha" => "2009"
                        "volumen" => "8"
                        "paginaInicial" => "75"
                        "paginaFinal" => "77"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19221540"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            17 => array:3 [
              "identificador" => "bib0090"
              "etiqueta" => "18&#46;"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Twelve-year analysis of severe cases of drug reaction with eosinophilia and systemic symptoms&#58; a cause of unpredictable multiorgan failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "Eshki M&#46;"
                            1 => "Allanore L&#46;"
                            2 => "Musette P&#46;"
                            3 => "Milpied B&#46;"
                            4 => "Grange A&#46;"
                            5 => "Guillaume J&#46;C&#46;"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archderm.145.1.67"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Dermatol"
                        "fecha" => "2009"
                        "volumen" => "145"
                        "paginaInicial" => "67"
                        "paginaFinal" => "72"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19153346"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
          ]
        ]
      ]
    ]
  ]
  "idiomaDefecto" => "en"
  "url" => "/16652681/0000000900000002/v1_201907070740/S1665268119316631/v1_201907070740/en/main.assets"
  "Apartado" => array:4 [
    "identificador" => "77718"
    "tipo" => "SECCION"
    "en" => array:2 [
      "titulo" => "Case Report"
      "idiomaDefecto" => true
    ]
    "idiomaDefecto" => "en"
  ]
  "PDF" => "https://static.elsevier.es/multimedia/16652681/0000000900000002/v1_201907070740/S1665268119316631/v1_201907070740/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/"
  "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1665268119316631?idApp=UINPBA00004N"
]
Article information
ISSN: 16652681
Original language: English
The statistics are updated each day
Year/Month Html Pdf Total
2024 November 2 0 2
2024 October 27 7 34
2024 September 50 5 55
2024 August 43 4 47
2024 July 66 10 76
2024 June 47 3 50
2024 May 42 1 43
2024 April 46 4 50
2024 March 50 15 65
2024 February 39 9 48
2024 January 53 8 61
2023 December 35 5 40
2023 November 32 1 33
2023 October 56 8 64
2023 September 45 2 47
2023 August 37 5 42
2023 July 43 2 45
2023 June 40 5 45
2023 May 58 4 62
2023 April 56 3 59
2023 March 46 1 47
2023 February 24 3 27
2023 January 21 4 25
2022 December 19 6 25
2022 November 22 7 29
2022 October 19 9 28
2022 September 16 5 21
2022 August 17 8 25
2022 July 31 6 37
2022 June 11 6 17
2022 May 15 10 25
2022 April 9 9 18
2022 March 22 8 30
2022 February 8 8 16
2022 January 18 5 23
2021 December 12 15 27
2021 November 10 7 17
2021 October 27 7 34
2021 September 28 12 40
2021 August 8 7 15
2021 July 13 5 18
2021 June 21 8 29
2021 May 14 4 18
2021 April 21 17 38
2021 March 14 6 20
2021 February 4 3 7
2021 January 12 10 22
2020 December 8 3 11
2020 November 7 6 13
2020 October 5 4 9
2020 September 13 4 17
2020 August 10 4 14
2020 July 3 1 4
2020 June 10 3 13
2020 May 9 5 14
2020 April 3 0 3
2020 March 7 2 9
2020 February 5 0 5
2020 January 6 2 8
2019 December 6 7 13
2019 November 3 0 3
2019 October 0 3 3
2019 September 2 1 3
2019 August 1 0 1
2019 July 2 4 6
Show all

Follow this link to access the full text of the article

es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos