Isolated ileal perforation due to cytomegalovirus reactivation during management of terbinafine hypersensitivity

We report a case of 71-year-old man who developed a hypersensitivity syndrome associated with terbinafine. He was placed on terbinafine (250 mg/d) for the treatment of tinea pedis due to diabetes mellitus. Following the treatment with terbinafine, he developed druginduced hypersensitivity syndrome (DIHS). Systemic corticosteroid led to transient improvement of his clinical manifestations. Three months after disease onset, he presented with panperitonitis due to ileal perforation, and underwent an emergency operation. The affected ileum was resected and ileostomy was performed in the terminal ileum. Cytomegalovirus (CMV)-specific IgG antibodies were significantly increased, high-titer CMV antigenemia was detected, and pathological examination of the resected ileum confirmed CMV infection. Based onthese observations, we strongly recommend that physicians monitor reactivation of the family of herpesvirus other than herpesvirus 6, to manage DIHS properly.

Phenytoin Induced Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS): Case Report

Background: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and potentially life-threatening condition. It presents a long prodromal period, extensive rash, fever, lymphadenopathy, hematologic abnormalities (eosinophilia with or without atypical lymphocytosis), and internal organ involvement. Purpose: To describe a case of phenytoin induced DRESS syndrome, presenting diagnostic and management challenges of clinical interest. Methods: The Consensus-based Clinical Case Reporting Guideline Development (CARE) was observed for data analysis in case reports. Case Report: A 22-year-old man, using phenytoin for 60 days, sought medical attention due to fever and maculopapular cutaneous lesions. He presented lymphocytosis with eosinophilia and severe acute hepatitis 24 hours after admission day. Hepatic transaminases returned to reference levels after phenytoin withdrawal, and eosinophilia and cutaneous manifestations did not respond well to systemic steroids. A forearm biopsy showed findings suggestive of severe cutaneous adverse reaction. The patient’s microscopic and clinical characteristics meet all criteria in the scoring systems of Bocquet et al., Registry of Severe Cutaneous Adverse Reaction (RegiSCAR), and Japanese Research Committee on Severe Cutaneous Adverse Reaction (J-SCAR), being highly suggestive of DRESS syndrome very probably caused by phenytoin. The complete remission of symptoms was achieved weeks after admission. Conclusions: DRESS syndrome is a defiant reaction. Clinicians must be aware of potential causative drugs and perform a complete clinical examination using the available resources, including laboratory tests and histopathological assessment. The clinical remission relies on the withdrawal of the culprit drug. Particular attention should be given to the involvement of internal organs.

Severe cutaneous adverse drug reactions： a review on epidemiology, etiology, clinical manifestation and pathogenesis

Purpose To review the current progress in epidemiology, etiology, clinical manifestation, and pathophysiology of severe cutaneous adverse drug reactions （SCADRs）. Data sources Data were acquired by using Blackwell-Synergy, PubMed, original articles published in the main Chinese journals and related medical textbooks materials. Study selection and data extraction Throughout the literature review 49 articles were selected. Results SCADRs cases are rare, however, the implication is life threatening with significant mortality rates. Epidemiology studies have shown various incidences from different regions, gender, age, race and concurrent illness. There are typical signs and symptoms for each type of SCADRs, but this is not always so. Drugs associated with inducing SCADRs are anticonvulsants, antibiotics, NSAIDs and antirheumatic drugs. In some countries, especially in Asia, traditional drugs are often the cause of SCADRs. Genetic polymorphisms and viral infections are predisposition factors of SCADRs. Patients with certain genetic alleles and underlying diseases are vulnerable to SCADRs. The exact pathogenesis of SCADRs is not well defined. Nonetheless, recent study showed that reactive metabolites and immunological processes have a significant role in SCADRs. Conclusions The different SCADRs reactions are attributed by different intrinsic factors, such as genetic polymorphisms, gender, age and race as well as extrinsic factors, such as underlying diseases. Different regions and culprit drugs also play a role in the various types of SCADRs.

Recognition of self and altered self by T cells in autoimmunity and allergy

T cell recognition of foreign peptide antigen and toler-ance to self peptides is key to the proper function of the immune system.Usually,in the thymus T cells that rec-ognize self MHC+self peptides are deleted and those with the potential to recognize self MHC+foreign pep-tides are selected to mature.However there are excep-tions to these rules.Autoimmunity and allergy are two of the most common immune diseases that can be related to recognition of self.Many genes work together to lead to autoimmunity.Of those,particular MHC alleles are the most strongly associated,reflecting the key importance of MHC presentation of self peptides in autoimmunity.T cells specific for combinations of self MHC and self pep-tides may escape thymus deletion,and thus be able to drive autoimmunity,for several reasons:the relevant self peptide may be presented at low abundance in the thy-mus but at high level in particular peripheral tissues;the relevant self peptide may bind to MHC in an unusual register,not present in the thymus but apparent else-where;finally the relevant self peptide may be post translationally modified in a tissue specific fashion.In some types of allergy,the peptide+MHC combination may also be fully derived from self.However the combi-nation in question may be modified by the presence of other ligands,such as small drug molecules or metal ions.Thus these types of allergies may act like the post translationally modified peptides involved some types of autoimmunity.

Active Monitoring of Adverse Drug Reactions with Neural Network Technology

INTRODUCTIONAn adverse drug reaction （ADR） is unintended injuries caused by the drug at normal doses during normal use. ADR monitoring is a long-term work of medical institutions. Medical institutions at all levels have their corresponding requirements of reporting ADRs.i On December 12, 2010, the National Health and Family Planning Commission of the People＇s Republic of China issued the ＂Administration of adverse drug reaction report and monitoring＂. The aims were to enhance drug postmarketing surveillance, standardize ADR monitoring and reporting, and control drug risks in a timely and effective manner to ensure the safety of patients.