How to manage DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) syndrome without a rash?

From the Research

Managing DRESS syndrome without a rash requires prompt recognition and treatment, with immediate discontinuation of the suspected culprit medication and initiation of systemic corticosteroids, typically starting with prednisone 1-2 mg/kg/day or equivalent, as the mainstay of treatment. The diagnosis of DRESS syndrome can be challenging, especially in the absence of a rash, but it may present with fever, lymphadenopathy, eosinophilia, and internal organ involvement, particularly liver dysfunction, which occurs in approximately 80% of cases 1.

Key Considerations in Management

• Immediate discontinuation of the suspected culprit medication is crucial 2, 3, 4, 1, 5
• Systemic corticosteroids are the mainstay of treatment, with a slow taper over 6-8 weeks to prevent rebound symptoms 2, 1
• Supportive care, including fluid and electrolyte management, antipyretics for fever, and close monitoring of organ function, is essential 2, 1
• In severe cases with organ involvement, methylprednisolone 1 g/day for 3 days may be initiated before transitioning to oral steroids 2
• Alternative immunosuppressants, such as cyclosporine or IVIG, may be considered in steroid-resistant cases 1

Monitoring and Follow-Up

• Patients should be monitored for at least 6 months after resolution due to potential flares or development of autoimmune conditions 1
• Regular laboratory tests, including complete blood count, liver function tests, kidney function tests, and eosinophil counts, are necessary to closely monitor organ function 2, 1

Recent Evidence and Recommendations

The most recent study 1 provides a comprehensive review of the literature and treatment algorithm for DRESS syndrome, emphasizing the importance of prompt recognition and treatment, as well as the use of systemic corticosteroids as the mainstay of treatment. Another recent study 3 highlights the importance of early diagnosis and treatment in improving outcomes, and notes that plasmapheresis or pulse steroid therapy may be used in severe cases with organ involvement.