Ayşe Yenigün

DRESS syndrome developed related to acetylsalicylic acid use

To the Editor, DRESS (Drug Rash with Eosinophilia and Systemic Symptoms) syndrome is a severe, unexpected drug reaction which affects several organ systems concurrently. The difference in this hypersensitivity reaction is internal organ involvement and hematologic changes. If not treated early, its mortality is high. DRESS syndrome was first described in 1940s with the use of hydantoin when it was started to be utilized (1). The pathogenesis of the illness is not completely clarified. Increased metabolites depending on insufficiency in the detoxification of liable drug is thought to cause immunologic reaction (2, 3). Nevertheless, the reactivation of herpes viruses by some factors such as human herpes virus 6 (HHV-6), HHV-7, Epstein–Barr virus (EBV), and cytomegalovirus (CMV) is regarded to stimulate the syndrome with the use of drug (2, 3). Due to high mortality risk, the early diagnosis of the disease and convenient treatment approach are important. The information regarding the illness is generally limited with the cases presented in the literature. DRESS syndrome is frequently described with antiepileptic drug use. Allopurinols and sulfonamide are other accused drugs. DRESS syndrome concerning the use of acetylsalicylic acid use has been reported in the literature, very few. In this study, we presented a 9-year-old patient diagnosed with acute articular rheumatism whose DRESS syndrome findings developed while receiving acetylsalicylic acid at 3 gr/ day dose. A 9-year-old female patient referred to our polyclinic with arthritis and mild carditis symptoms was hospitalized with acute rheumatic fever. Arthritis findings disappeared after a short time when acetylsalicylic acid treatment was initiated at anti-inflammatory dose (3 gr/day) with bed rest. The patient was discharged from hospital after she had been hospitalized for 8 days and followed up. It was planned that bed rest and acetylsalicylic acid use at the same dosage would be continued and this schedule would be completed in 2 weeks. It was decided that physical examination and laboratory evaluations would be carried out 1 week later when our polyclinic and treatment period was planned. The patient applied to our emergency service (the day before the polyclinic control, i.e., on the 15th day of acetylsalicylic acid treatment) with weakness, vomiting, widespread rash all over the body, redness, and itching. In the laboratory findings examined, liver enzyme elevation was determined. The patient was hospitalized with acetylsalicylic acid intoxication prediagnosis and acetylsalicylic acid treatment was terminated. In the physical examination of our patient, the following were determined: weight 42 kg (90 percentile), height 105 cm (75 percentile), body temperature: 38.5°C, respiratory rate: 20/min, TA 100/60 mmHg, heart rate: 110/min, and cardiac sounds were also rhythmic. It could be palpated as 3 cm from liver midclavicular line. There were numerous cervical micro lymphadenopathies. There were widespread maculopapular rashes all over the body, and in addition, there were urticarial rashes that were likely to be discolored and unite when pressed (Fig. 1). There were no arthritis findings or arthralgia complaints. In her anamnesis, there was an allergic rhinitis history and acute rheumatic fever (ARF) in paternal family history. In the first laboratory findings obtained at emergency service, the following were established: hemoglobin (Hb):13.2 gr/dl, leukocyte: 9750 mm3, hematocrit (Hct): %39.3, thrombocyte: 35,5000/mm, sedimentation: 80 mm/h, C-reactive protein (CRP): 89 mg/l, urea: 22 mg/dl, creat: 0.69 mg/dl, aspartate aminotransferase (AST): 482 U/l, alanine aminotransferase (ALT): 397 U/l, and ammonia: 87 (31–123) ug/dl. The pre-diagnosis for the patient who had vomiting, weakness, and transaminase elevation from the laboratory workup was acetylsalicylic acid intoxication. As blood acetylsalicylic acid level could not be examined at our hospital in that period, we sent samples to a center out of the hospital. After we terminated acetylsalicylic acid treatment, transaminase levels continued to increase in daily controls. Blood acetylsalicylic acid level obtained after 48 h was identified as 18 mg/dl— within normal limits. ALT levels raised 30-fold of normal

Akut Solunum Yolu Enfeksiyonlu Çocuk ve Erişkin Hastalarda Rinovirüs Genotiplerinin Belirlenmesi

Rhinovirus (RV) is one of the most frequent causative agent of acute respiratory tract infections in the world. The virus may cause a mild cold, as well as more serious clinical symptoms in patients with immune system deficiency or comorbidities. Rhinoviruses have been identified by molecular methods under three types: RV-A, RV-B and RV-C. In most of the cases, it was reported that RV-A and RV-C were related with lower respiratory tract infections and asthma exacerbations, while RV-B was rarely reported in lower respiratory tract infections. The main objective of this study was to investigate RV species by sequence analysis in nasopharyngeal samples in pediatric and adult patients who were admitted to hospital with acute respiratory tract infections and to establish the relationship between species and age, gender and clinical diagnosis of the patients. Secondly, it was planned to emphasize the efficiency of the sequence analysis method in the determination of RV species. One hundred twenty seven patients (children and adults) who were followed up with acute respiratory tract infections in our university hospital were evaluated between January 2014 and January 2016. Viral loads were determined by quantitative real-time PCR in RV positive patients detected by a commercial kit in nasopharyngeal swab specimens. Thirty-one samples whose viral loads could not be determined were excluded from the study. The remaining 96 samples (50 children and 46 adults) were retested by conventional PCR using the target of VP4/VP2 gene region. A total of 65 samples (32 adults and 33 children) with the bands (549 bp) corresponding to the VP4/VP2 gene regions after the conventional PCR were analyzed by DNA sequencing. A phylogenetic tree was constructed using the neighbour-joining method. After sequence analysis it was determined that 28 (43.07%) were RV-A, 7 (10.76%) were RV-B and 28 (43.07%) were RV-C; and moreover one of each enterovirus (EV) species EV-D68 (1.53%) and EV-C (1.53%) were detected. The distribution of the species in adults was: 15 (48.3%) RV-A, 5 (16.1%) RV-B and 11 (35.4%) RV-C. The distribution of the species in children was 13 (40.6%) RV-A, 2 (6.3%) RV-B and 17 (53.1%) RV-C. RV-A is more frequent in adults, while RV-C is more frequent among children. It has been observed that RV-C infection is detected in children with bronchiolitis, while RV-A infection is detected in adults with pneumonia. There was no statistically significant difference between RV species and clinical diagnosis, age and gender in both of the age groups (p> 0.05). In conclusion, this is the first study that reports the frequency of RV species in children and adult patients with acute respiratory tract infections; the frequency of RV-A and RV-C species were found to be similar but higher than RV-B species in all age groups. RV-C and RV-A was the highest species seen in children and adult patients, respectively. There is a need for further research to identify the types of RV circulating in the community and the prevalence of infections caused by the species.