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Clinical and laboratory features of severe drug eruptions

Clinical and laboratory features of severe drug eruptions
Syndrome Rash morphology Localization Timing Internal organ involvement Systemic signs Laboratory findings
DHS/DRESS

Maculopapular exanthem

Erythroderma

Facial edema

Generalized

Mucosal involvement infrequent
>14 days

Lymphadenopathy

Hepatitis

Pneumonitis

Nephritis

Fever

Malaise

Fatigue

Eosinophilia, atypical lymphocytes

Abnormal liver, renal function tests
AGEP

Widespread erythema

Erythroderma

Pustules (small, numerous)

Generalized, rarely flexural

Mucosal involvement rare
<3 days Possible but rare High fever (>38°C/100.4°F) Leukocytosis with neutrophilia (>7000/mm3)
SJS/TEN

Dusky red, coalescent macular exanthem

Atypical target lesions

Bullous lesions

Epidermal necrosis (<10% in SJS, 10 to 30% in SJS/TEN, >30% in TEN)

Nikolsky sign (ready removal of the epidermis with slight tangential pressure)

Disseminated

Mucosal involvement nearly in all cases (stomatitis, conjunctivitis)
4 to 21 days Pneumonitis

Fever

Malaise

Fatigue

Sore throat

Dysphagia, photophobia

Lymphopenia

Epidermal necrosis on skin biopsy with full thickness loss of epidermis
DHS/DRESS: drug hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms; AGEP: acute generalized exanthematous pustulosis; SJS/TEN: Stevens-Johnson syndrome/toxic epidermal necrolysis.
Adapted from:
  1. Scherer K, Bircher A. Adverse drug reactions and the skin--from trivial to fire signal. Internist (Berl) 2009; 50:171.
  2. Bircher AJ, Scherer K. Delayed cutaneous manifestations of drug hypersensitivity. Med Clin North Am 2010; 94:711.
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