Are Liver Enzymes Elevated in DRESS Syndrome?
Yes, liver enzyme elevation is a hallmark feature of DRESS syndrome and represents one of the most common and clinically significant organ manifestations of this severe drug hypersensitivity reaction. 1, 2, 3
Hepatic Involvement as a Core Feature
Hepatitis with elevated transaminases (ALT, AST) is the primary organ manifestation in DRESS syndrome. 4 The liver is frequently involved, presenting as:
- Elevated liver function tests (LFTs) including transaminases and cholestatic parameters that can increase dramatically during the course of the syndrome 5
- ALT levels exceeding 2 times the upper limit of normal, which is part of the RegiSCAR diagnostic criteria for organ involvement 3
- Immune-mediated hepatitis that can progress to severe acute hepatitis or even acute liver failure in some cases 1, 6
Clinical Patterns and Severity
The hepatic manifestations in DRESS syndrome follow specific patterns:
- Liver enzyme elevations typically develop after the initial presentation, sometimes appearing normal at admission but then dramatically increasing during hospitalization 5
- The severity ranges from mild transaminitis to fulminant liver failure, with the latter carrying significant mortality risk 6, 7
- Mortality in DRESS syndrome (5-20%) is frequently attributed to hepatic complications, particularly fulminant liver failure 5, 7
Diagnostic Workup
A comprehensive metabolic panel evaluating liver function (ALT, AST, alkaline phosphatase, bilirubin) is crucial in diagnosing DRESS syndrome. 3 The workup should include:
- Complete blood count with differential to assess for eosinophilia (>700/μL or >10%) 3
- Serial monitoring of liver enzymes as they may worsen despite initial treatment 5, 7
- Kidney function tests (BUN, creatinine) as renal involvement can coexist 3, 4
Treatment Response
After appropriate treatment with systemic corticosteroids and/or IVIG, liver enzymes typically improve substantially within a median time of 13 days (range 0-27 days). 8 However:
- Immediate withdrawal of the causative drug is the most crucial first step, as continued exposure worsens hepatic injury 2, 6
- Systemic corticosteroids are the mainstay of treatment for DRESS syndrome with hepatic involvement, unlike in Stevens-Johnson syndrome where they may be contraindicated 2
- IVIG at 1-2 g/kg total dosage should be considered in patients not responding to systemic steroids 2, 8
Common Pitfalls
Do not dismiss normal initial liver enzymes as ruling out DRESS syndrome—they can be normal at presentation and then dramatically increase during the disease course. 5 Additionally:
- The latency period of 2-6 weeks (typically 6 weeks) after drug initiation helps distinguish DRESS from other drug reactions 2, 3
- Eosinophilia may develop after liver enzyme elevation, so timing of laboratory abnormalities varies 5
- Prolonged steroid taper over at least 4 weeks is necessary to prevent relapse, as DRESS involves T-cell immune-directed toxicity 2