Management of patients with tuberculosis medication-induced drug reaction with eosinophilia and systemic symptoms

Tuberculosis (TB) incidence is rising globally, and TB medication-associated drug reaction with eosinophilia and systemic symptoms (DRESS) presents a significant clinical challenge, particularly in people living with HIV (PLH). Treatment interruption during active TB, especially with comorbid immunosuppression can be detrimental. This review highlights global variations in management practices and emphasizes the need for a more personalized approach to care.

Timely cessation of the suspected medication, supportive care, and topical corticosteroids remain central to DRESS management. However, the routine use of systemic corticosteroids remains debated, as good outcomes from topical steroids alone have been observed, especially in TB/HIV co-infected patients. Efforts to reduce TB treatment interruption have driven interest in the use of shortened TB regimens, sequential additive drug challenge (SADC) with stat dose intravenous corticosteroids to limit positive drug challenge morbidity, and even desensitization protocols. Although not yet widely adopted, these strategies show promise in reintroducing first-line TB drugs, limiting treatment interruptions. Management remains complex, with prolonged hospital stays and high healthcare costs continuing to drive innovation.

The findings support a move towards personalized approaches to TB-DRESS management, with future efforts focused on integrating clinical, genomic, and in-vitro tools to guide risk-stratified reintroduction of TB medications.