Please login or create an account. If you do not have access to this content, you will be shown a 30 second preview and licensing options.
- Presentation
Viral Exanthems and Viral Reactivation in DRESS Syndrome
Description
The talk reviewed how viral infections and drug reactions can both cause morbilliform eruptions, using a case of a vaccinated 19-year-old who developed rash, facial edema, lymphocytosis, transaminitis, and AKI after amoxicillin, later found to have acute EBV infection. The speaker emphasized that EBV, CMV, HHV-6/7, and acute HIV can present with mononucleosis-like syndromes and rashes, and that viral reactivation is common in DRESS/DIHS, with HHV-6, EBV, and CMV often reappearing after onset. The lecture then organized viral exanthems by clinical pattern: under- or unimmunized patients with measles or rubella; upper respiratory viruses such as adenovirus, influenza, and COVID-19; mononucleosis-like illnesses including EBV, CMV, HHV-6/7, and acute HIV; viruses causing arthralgias/myalgias such as parvovirus B19, chikungunya, dengue, and Zika; and viruses with oral/acral involvement such as enteroviruses. It concluded with practical clues to distinguish viral from drug eruptions: vesicles and enanthems favor viral causes, pustules and pruritus favor drugs, bright red eruptions and seasonal/summer clustering suggest viral etiologies, while trunk-predominant duskier eruptions and systemic illness may point toward drug reactions or more complex cases.
View moreConclusions
- Viral reactivation is common in DRESS/DIHS and may occur weeks after onset, recur with flare-ups, and involve HHV-6, EBV, CMV, and sometimes HHV-7.
- Detection of viremia in DRESS does not by itself prove a primary viral infection, so viral results must be interpreted in the clinical context.
- Morbilliform eruptions have a broad viral differential that includes measles, rubella, adenovirus, influenza, COVID-19, EBV, CMV, HHV-6/7, parvovirus, arboviruses, and enteroviruses.
- In underimmunized patients, measles and rubella remain important causes of morbilliform rash and should be considered early because of their systemic complications and transmissibility.
- In vaccinated patients with URI symptoms and morbilliform rash, respiratory viral testing for influenza and COVID-19 is an important part of evaluation.
- A mononucleosis-like syndrome with rash can be caused by EBV, CMV, HHV-6/7, or acute HIV, and these infections can overlap clinically with drug eruptions.
- Several viruses can produce rashes after beta-lactam exposure, making it difficult to distinguish a true drug eruption from a viral exanthem.
- Clinical clues favoring a viral exanthem include enanthem, vesicles, brighter erythema, systemic infectious symptoms, and spring/summer seasonality.
- Clinical clues favoring a drug eruption include pruritus, dusky color, trunk/proximal predominance, and lack of enanthem.
- Although viral and drug morbilliform eruptions overlap substantially, pattern recognition plus targeted testing can improve diagnostic accuracy.
- An Bras Dermatol. 2024. DRESS syndrome: an interaction between drugs, latent viruses, and the immune system.#10.1016/j.abd.2023.12.010
- Clin Case Rep. 2023 Nov 4; 11(11): e8160.
- CMAJ. 2010 Feb 23;182(3): E146.
- J. Dermatol Sci. 2020 May; 98(2):75-81.
- JAAD. 2012 Dec;67(6):1282-8.
- BJD. 2002 Aug;147(2):255-60.
- Viral exanthems: An update on laboratory testing of the adult patient. Journal of the American Academy of Dermatology.#10.1016/j.jaad.2016.08.034