DRESS or ‘picture of DRESS’

I read with great interest Lopez-Anglada's case report.¹ The authors concluded that this patient developed a DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms). I am not sure whether this patient really developed a DRESS or a ‘picture of DRESS’. This case report raises a very important question. It is now well established that DRESS is a consequence of an immune response against herpesvirus reactivation. We recently demonstrated that the cutaneous and visceral manifestations of DRESS are mediated by activated CD8+ T lymphocytes, which are directed against viruses such as EBV, HHV-6, HHV-7 or CMV.² In DRESS, viral reactivations are induced by some drugs. How these drugs may induce herpesvirus reactivation is not yet understood. It was recently demonstrated that DRESS-associated drugs may increased in vitro HHV-6 and EBV replication.³ The ‘DRESS picture’ is also not specific because it is only the consequence of a strong antiviral immune response that may lead to multi-organ failure.⁴ Lopez-Anglada et al. described in this case report a ‘DRESS picture’ consecutive to a severe viral reactivation. No offending drug was associated in this case. ‘DRESS picture’ is also observed in other situations such as immunocompromised patients or patients in intensive care units. The description and the better knowledge of DRESS must help us to identify these manifestations as a consequence of viral reactivation. Brands-Nijenhuis et al.⁵ recently reported a case of HHV-6 reactivation in a transplant recipient. This patient also developed a ‘DRESS picture’. Another point is the possible relationship between herpesvirus reactivation, antiviral immune reaction and GVHD. Viral reactivation may be a differential diagnosis of GVHD. But in this latter case, HHV-6 reactivation developed before GVHD and may participate to the development of GVHD. ‘DRESS picture’ must be well known to identify manifestations of viral reactivation that may warrant specific antiviral treatment.