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General lnternal Medicine Drug Allergy Diagnosis Medications can produce almost any pattern of skin disease. The most common types of cutaneous adverse reactions are exan thematous/morbilliform, urticarial, fixed drug, and photosensitivity; drug induced hypersensitMty syndrome; hypersensitivity vasculitis; acute generalized exanthematous pustulosis; and the severe cutaneous adverse reactions SJS and toxic epidermal necrolysis.

Drug Allergy Diagnosis Medications can produce almost any pattern of skin disease. The most common types of cutaneous adverse reactions are exan thematous/morbilliform, urticarial, fixed drug, and photosensitivity; drug induced hypersensitMty syndrome; hypersensitivity vasculitis; acute generalized exanthematous pustulosis; and the severe cutaneous adverse reactions SJS and toxic epidermal necrolysis. STUDY TABIE: Common Drug-Mediated Skin Eruptions TyPe Description Acute generalized exanthematous Acute onset of widespread pustules, fever, leukocytosis, and possibly eosinophilia pustulosis Usually self-limiting and clears without residual skin changes approximately 2 weeks after drug cessation Drug-induced hypersensitivity Acute onset of generalized papular eruption, facial edema, fever, arthralgia, generalized syndrome (also known as DRESS) lymphadenopathy, elevated serum aminotransferase levels, eosinophilia, and lymphocytosis EM, SJS, TEN Spectrum ranges from classic target lesions (EM), to involvement of mucous membranes with systemic symptoms (SJS), to a life-threatening loss of epidermis (TEN) SJS involves <1 07o, SJS/TEN overlap involves 10o/o-307", and TEN involves >30% skin detachment Erythema nodosum Tender subcutaneous nodules on lower leg; often preceded by a prodrome of fever, malaise, and/or arthralgia Causes fall into three broad categories: infections, drugs, and systemic diseases (usually inflammatory disorders) Fixed drug eruption Discrete, often round or oval lesions that recur in exactly the same spot when rechallenged with the drug Maculopapular and morbilliform Mostcommontypeof drug reaction; symmetricdistribution, usuallytruncal, hardlyeveron (small discrete papules) palms or soles, and associated with fever and pruritus Red man syndrome Bodyflushing, hypotension, and muscle pain associated with vancomycin and ciprofloxacin U rticarial Second most common drug reaction type with or without angioedema

STUDY TABIE: Common Drug-Mediated Skin Eruptions TyPe Description Acute generalized exanthematous Acute onset of widespread pustules, fever, leukocytosis, and possibly eosinophilia pustulosis Usually self-limiting and clears without residual skin changes approximately 2 weeks after drug cessation Drug-induced hypersensitivity Acute onset of generalized papular eruption, facial edema, fever, arthralgia, generalized syndrome (also known as DRESS) lymphadenopathy, elevated serum aminotransferase levels, eosinophilia, and lymphocytosis EM, SJS, TEN Spectrum ranges from classic target lesions (EM), to involvement of mucous membranes with systemic symptoms (SJS), to a life-threatening loss of epidermis (TEN) SJS involves <1 07o, SJS/TEN overlap involves 10o/o-307", and TEN involves >30% skin detachment Erythema nodosum Tender subcutaneous nodules on lower leg; often preceded by a prodrome of fever, malaise, and/or arthralgia Causes fall into three broad categories: infections, drugs, and systemic diseases (usually inflammatory disorders) Fixed drug eruption Discrete, often round or oval lesions that recur in exactly the same spot when rechallenged with the drug Maculopapular and morbilliform Mostcommontypeof drug reaction; symmetricdistribution, usuallytruncal, hardlyeveron (small discrete papules) palms or soles, and associated with fever and pruritus Red man syndrome Bodyflushing, hypotension, and muscle pain associated with vancomycin and ciprofloxacin U rticarial Second most common drug reaction type with or without angioedema The appearance of a maculopapular rash is associated with the use of ampicillin in EBV and CMV infections or underlying ALL. This is not a drug allergr. Duration of the rash is independent of whether the drug is continued. DON'T BETRICKED . The absence of eosinophilia does not rule out drug reaction or DRESS.

STUDY TABIE: Common Drug-Mediated Skin Eruptions TyPe Description Acute generalized exanthematous Acute onset of widespread pustules, fever, leukocytosis, and possibly eosinophilia pustulosis Usually self-limiting and clears without residual skin changes approximately 2 weeks after drug cessation Drug-induced hypersensitivity Acute onset of generalized papular eruption, facial edema, fever, arthralgia, generalized syndrome (also known as DRESS) lymphadenopathy, elevated serum aminotransferase levels, eosinophilia, and lymphocytosis EM, SJS, TEN Spectrum ranges from classic target lesions (EM), to involvement of mucous membranes with systemic symptoms (SJS), to a life-threatening loss of epidermis (TEN) SJS involves <1 07o, SJS/TEN overlap involves 10o/o-307", and TEN involves >30% skin detachment Erythema nodosum Tender subcutaneous nodules on lower leg; often preceded by a prodrome of fever, malaise, and/or arthralgia Causes fall into three broad categories: infections, drugs, and systemic diseases (usually inflammatory disorders) Fixed drug eruption Discrete, often round or oval lesions that recur in exactly the same spot when rechallenged with the drug Maculopapular and morbilliform Mostcommontypeof drug reaction; symmetricdistribution, usuallytruncal, hardlyeveron (small discrete papules) palms or soles, and associated with fever and pruritus Red man syndrome Bodyflushing, hypotension, and muscle pain associated with vancomycin and ciprofloxacin U rticarial Second most common drug reaction type with or without angioedema The appearance of a maculopapular rash is associated with the use of ampicillin in EBV and CMV infections or underlying ALL. This is not a drug allergr. Duration of the rash is independent of whether the drug is continued. DON'T BETRICKED . The absence of eosinophilia does not rule out drug reaction or DRESS. Treatment Discontinue the offending medication, systemic and/or topical glucocorticoids, and oral Hr antihistamines as needed'

The appearance of a maculopapular rash is associated with the use of ampicillin in EBV and CMV infections or underlying ALL. This is not a drug allergr. Duration of the rash is independent of whether the drug is continued. DON'T BETRICKED . The absence of eosinophilia does not rule out drug reaction or DRESS. Treatment Discontinue the offending medication, systemic and/or topical glucocorticoids, and oral Hr antihistamines as needed' Treat drug induced hypersensitivity syndrome with systemic glucocorticoids. SJS/TEN treatment is supportive (fluid and electrolyte management, wound care); the effectiveness of IVIG and glucocorticoids is uncertain. TESTYOURSETF A lS-year-old student is given ampicillin for headache, pharyngitis, cervical lymph node enlargement, fever, and lymphocytosis on CBC. He develops a diffuse maculopapular rash. ANSWER: Choose EBV infection (infectious mononucleosis) for diagnosis; do not select drug rash. 173