Bronchopulmonary involvement in severe cutaneous adverse reactions

Skin is one of the most common targets of adverse drug reactions. Life-threatening skin adverse reactions include Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), and drug rash with eosinophilia and systemic symptoms (DRESS). SJS and TEN are characterized by skin and mucous membrane detachments. Respiratory complications occur in about 40% of the cases, and can be related to specific bronchial epithelial injuries as well as to nonspecific manifestations like infection, pulmonary edema, and atelectasis. Mechanical ventilation is required in about 25% of cases. Bronchoscopy is warranted in mechanically ventilated patients to remove detached mucous membranes and prevent airway obstruction. Pulmonary involvement in DRESS is rare and related to lung infiltration by eosinophils, which rarely leads to the acute respiratory distress syndrome. The most severe cases of DRESS usually present other organ involvement like cytolytic hepatitis and are usually reversible after steroid treatment. Removal of the involved drug is warranted.