What are the potential complications of DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) Syndrome, particularly in elderly patients or those with pre-existing liver or kidney disease?

Complications of DRESS Syndrome

DRESS syndrome carries significant morbidity and mortality, with approximately 10% of patients dying primarily from visceral organ compromise, and multi-organ failure representing the most severe complication. 1, 2

Organ-Specific Complications

Hepatic Complications

• Hepatitis is the most common organ manifestation, presenting with ALT >2 times the upper limit of normal 1
• Elevated transaminases can progress to hepatic failure in severe cases 3
• Liver involvement occurs in approximately 74% of patients 4

Renal Complications

• Nephritis with creatinine >1.5 times baseline is a defining feature of kidney involvement 1
• Acute kidney injury may present with hematuria and proteinuria 3
• Elevated urea/creatinine occurs in 32% of patients 4
• Elevated serum creatinine at presentation predicts fatal outcomes 1

Cardiac Complications

• Myocarditis and pericarditis can occur as part of multi-organ involvement 1, 5
• Troponin elevation is present in 42% of patients, indicating cardiac injury 4

Hematologic Complications

• Eosinophilia (≥0.7 × 10⁹/L) occurs in 95% of patients and typically peaks around 10 days after skin manifestations 4
• Leukocytosis is reported in 84% of patients 4
• Atypical lymphocytosis appears in 26% of cases 4
• Anemia or thrombocytopenia may occasionally develop 3

Ophthalmologic Complications

• Vision problems can occur due to papilledema with bilateral hemorrhage 6
• Mucous membrane involvement may require ophthalmology consultation 7

Pulmonary Complications

• Pneumonitis can develop as part of systemic involvement 5

Infectious Complications

• Infection risk is elevated due to both the syndrome itself and immunosuppressive treatment 8, 2
• Patients require infection prevention measures and appropriate infection control in intensive care settings 8, 2

Long-Term Complications

• Relapse occurs in approximately 12% of cases, particularly with DRESS associated with viral reactivation 5
• Some patients suffer from chronic complications even after recovery 2
• The syndrome involves reactivation of herpes family viruses (particularly EBV and HHV-6), which can influence severity 1, 6

Multi-Organ Failure

• Multi-organ failure represents the most severe complication and is the primary cause of the 10% mortality rate 2, 4
• Severity is directly related to the extent of systemic involvement 8

Special Considerations for High-Risk Populations

Elderly and Pre-existing Disease

• Patients with impaired renal clearance are at higher risk for severe complications, particularly when exposed to drugs like vancomycin 3
• Elevated serum ferritin levels at presentation predict fatal outcomes 1
• Higher lymphocyte counts indicate the need for systemic corticosteroids 1

Critical Pitfall

• Inadequate steroid tapering (less than 4 weeks) increases relapse risk due to the T-cell immune-directed nature of the toxicity 1, 5