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  • Writer's pictureTasha Tolliver

DRESS Syndrome and Myocarditis: The Heart of the Matter

DRESS Syndrome is a severe, cutaneous drug reaction that anyone can develop — and over 50 known medications (primarily antibiotics, anticonvulsants, and antigout) can cause this disease. DRESS stands for Drug Reaction with Eosinophilia and Systemic Symptoms. And myocarditis (heart inflammation) is an underappreciated result of having DRESS Syndrome.

a man lies on a hospital bed as a doctor conducts an echocardiogram on him
An echocardiogram is a critical diagnostic step in DRESS Syndrome patients that can help detect afflicted heart

DRESS typically develops between 2 and 8 weeks after starting a new medication. First symptoms include: fever, rash that spreads across your body, swollen lymph nodes, and facial swelling.

The longer you continue taking the medication, the more severe your reaction can become. DRESS can systemically affect many organs in your body, such as the skin, liver, lungs, kidneys, and heart.

While people who die from DRESS most commonly have liver failure, heart failure is an overlooked complication. Myocarditis can come on quickly and be highly and rapidly fatal. For this reason, medical teams should critically consider the heart in DRESS patients.

Key Highlights About Myocarditis in DRESS Syndrome Patients

How many DRESS Syndrome patients develop afflicted hearts?

13% of DRESS patients have some kind of heart involvement.

When do heart problems begin?

Issues with the heart can happen many days or even months after a patient first develops DRESS and after medical teams discharge them from the hospital. However, many patients who develop myocarditis from DRESS do not show heart-related symptoms during their initial hospitalization.

Often, patients will develop heart problems when they are reducing their intake of steroids. So, medical teams should closely follow the heart to look for any signs of trouble. Patients with myocarditis can be mildly symptomatic or have severe symptoms.

What forms of myocarditis are common with DRESS?

DRESS has two described forms of myocarditis:

  1. Hypersensitivity

  2. Acute necrotizing eosinophilic myocarditis (ANEM)

Patients with ANEM have more than a 50% chance of dying, which is one of the reasons this topic is so important.

Which drugs are commonly associated with myocarditis?

Case reports reveal that a number of drugs are associated with myocarditis. Some of the most common contributors to risk include:

  • Allopurinol

  • Ampicillin

  • Minocycline

  • Sulfonamides

What are the symptoms of eosinophilic myocarditis?

Symptoms can develop fast at any point during DRESS and may worsen quickly within 1 to 3 days. These first symptoms include:

  • Dyspnea – shortness of breath, an uncomfortable feeling of not able to breathe well enough

  • Tachycardia – when your heart beats faster (over 100 beats a minute)

  • Hypotension – blood pressure that’s much lower than normal

  • Chest pain – varies in symptoms from a sharp pain to a dull ache or chest tightness that can spread up the neck and jaw, and down the back and arms

  • Dizziness and lightheadedness

  • Nausea and vomiting

If you have any of these symptoms, let your doctor know immediately!

How should medical teams diagnose and monitor myocarditis in DRESS Syndrome?

Medical teams should assess patients while they’re hospitalized and for at least the first 6 months of having DRESS. Failing to do so could result in the patient’s death.

Cardiac screening tests include:

1. Baseline and periodic screening test – echocardiogram (ECG): This test is an ultrasound and noninvasive. The ECG will show:

  • the heart size

  • how blood flows through the heart valves

  • whether fluid is around the heart

This test differs from an electrocardiogram (ECC or EKG), which measures the heart’s rhythm and how it is beating. In addition to the ECG, DRESS experts recommend you will also need to do an ECC or EKG to properly monitor the heart.

2. Blood tests that show markers for heart issues: troponin and creatinine kinase

From there, if doctors suspect that the heart is affected, they’ll need to do a cardiac MRI (endomyocardial biopsy). This screening is highly sensitive and specific for detecting myocarditis.

We cannot stress enough how critical immediate medical care is for patients with myocarditis. Acting quickly and monitoring the heart for at least six months is highly important — this careful attention can be what saves a patient’s life!

Quick Guide to Diagnosing DRESS Syndrome and Myocarditis

a diagnostic guide for DRESS Syndrome and myocarditis

Further Reading About DRESS Syndrome and Myocarditis

To learn more about myocarditis in patients with DRESS Syndrome, we recommend the following researched-based resources:


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