Pediatric emergency medicine trisk 1309 1309
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DHR is a delayed-type hypersensitivity reaction that occurs 2 to 6 weeks, with
an average of 22 days, after starting a medication. Antiepileptics (carbamazepine,
phenytoin, phenobarbital, lamotrigine) are the most common cause of DHR.
Other medications that commonly cause DHR are trimethoprimsulfamethoxazole, minocycline, dapsone, sulfasalazine, and abacavir. There
appears to be a genetic susceptibility for developing DHR to certain medications.
For example, HLA-A*31:01 is associated with an increased risk of DHR
following exposure to carbamazepine in children. Other associations with DHR
include human herpesvirus-6 (HHV6), in which reactivation has been detected in
cases of DHR. Though the exact role of HHV6 in the pathogenesis of DHR is still
unclear, some evidence suggests that HHV6 reactivation creates immune
dysregulation that causes DHR, while others suggest that DHR-induced immune
dysregulation allows for HHV6 reactivation.
The main differential diagnosis for DHR includes a cutaneous-limited
morbilliform drug eruption, Kawasaki disease, and viral exanthem. The presence
of fever, facial edema, lymphadenopathy, and laboratory abnormalities
distinguishes DHR from a cutaneous-limited morbilliform eruption. The absence
of conjunctivitis and mucous membrane involvement suggests DHR rather than
Kawasaki disease. The initiation of a potential high-risk medication weeks before
rash onset increases the likelihood that an eruption is DHR rather than a viral
exanthem.
