Pediatric Emergency Unit, S.Orsola University Hospital, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, via Massarenti 9, 40138, Bologna, Italy.
Allergy Unit, Meyer Children's University Hospital, Florence, Italy.
Eur J Pediatr. 2021 Jul;180(7):2327-2332. doi: 10.1007/s00431-021-04010-5. Epub 2021 Mar 9.
In cases of skin eruptions over the course of antibiotic therapy and concomitant viral infection, differential diagnosis is often challenging. Confirming or ruling out drug hypersensitivity is not always a clear-cut question. Drug reaction with eosinophilia and systemic symptoms (DRESS) cases, for example, is classified as severe cutaneous adverse reactions due to drugs, but frequently the clinical manifestations do not completely fit into the diagnosis of DRESS. The aim of the present paper is to highlight similarities and differences among DRESS syndrome and DRESS-like rashes during viral infections and amoxicillin intake in children, in order to highlight those aspects that can help clinicians in early detection. We describe the dermatological, clinical, and laboratory characteristics of five patients hospitalized for DRESS-like skin rashes appearing roughly 1 week since the start of an amoxicillina course for upper respiratory tract infection (URTI) symptoms. The data are compared with those of 3 patients with early-onset DRESS syndrome. The absence of eosinophilia might be an initial marker to help identifying DRESS-like rashes; a quick clinical improvement and the confirmation of a viral infection able to explain the symptoms can help to finally rule out DRESS syndrome. Conclusion: A rapid, correct diagnosis of such DRESS-like rashes during viral infections allows more appropriate management and avoids unnecessary, life-long exclusion of useful and effective antibiotics because of a falsely "amoxicillin-allergy" labelling. What is Known: • Viral infections are common causes of skin rashes in children during antibiotic intake and may require differential diagnosis with drug reactions. • Early-onset DRESS syndrome is usually induced by antibiotics and appears ≤15 days after drug intake. What is New: • Prominent midface edema, maculopapular rash, and mild-to-moderate systemic symptoms may appear in children during viral illnesses treated with amoxicillin few days after drug intake, and may require differential diagnosis with early-onset DRESS. • In such cases, absence of eosinophilia, low (2-3) RegiSCAR score, confirmation of viral etiology, and a rapid resolution of the rash (2-5 days) might help to rule out DRESS; conversely, at an early stage, the presence of eosinophilia should suggest a diagnosis of DRESS.
在抗生素治疗过程中出现皮肤疹和同时发生病毒感染的情况下，鉴别诊断通常具有挑战性。确认或排除药物过敏并不总是一个明确的问题。例如，药物反应伴嗜酸性粒细胞增多和全身症状 (DRESS) 病例被归类为药物引起的严重皮肤不良反应，但临床表现并不总是完全符合 DRESS 的诊断。本文的目的是强调儿童在病毒感染和服用阿莫西林期间 DRESS 综合征和 DRESS 样皮疹之间的相似和不同之处，以便突出有助于临床医生早期发现的方面。我们描述了 5 名因上呼吸道感染 (URTI) 症状而开始服用阿莫西林约 1 周后出现 DRESS 样皮疹而住院的患者的皮肤科、临床和实验室特征。将这些数据与 3 名早期发病的 DRESS 综合征患者的数据进行比较。嗜酸性粒细胞减少可能是识别 DRESS 样皮疹的初始标志物；快速临床改善和确认能够解释症状的病毒感染有助于最终排除 DRESS 综合征。结论：在病毒感染期间迅速、正确地诊断出这种 DRESS 样皮疹可以进行更恰当的管理，并避免因错误地“阿莫西林过敏”标签而长期排除有用和有效的抗生素。已知：• 病毒感染是儿童在服用抗生素期间出现皮疹的常见原因，需要与药物反应进行鉴别诊断。• 早期发病的 DRESS 综合征通常由抗生素引起，并且在药物摄入后≤15 天出现。新内容：• 在病毒感染期间，接受阿莫西林治疗的儿童可能会出现明显的中面部水肿、斑丘疹和轻度至中度全身症状，这可能需要与早期发病的 DRESS 进行鉴别诊断。• 在这种情况下，嗜酸性粒细胞减少、低（2-3）RegiSCAR 评分、确认病毒病因以及皮疹迅速消退（2-5 天）可能有助于排除 DRESS；相反，在早期阶段，嗜酸性粒细胞增多应提示 DRESS 的诊断。
