Targeted therapy guided by single-cell transcriptomic analysis in drug-induced hypersensitivity syndrome: a case report

Nat Med. 2020 Feb;26(2):236-243. doi: 10.1038/s41591-019-0733-7. Epub 2020 Jan 20.

Abstract

Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms (DiHS/DRESS) is a potentially fatal multiorgan inflammatory disease associated with herpesvirus reactivation and subsequent onset of autoimmune diseases1-4. Pathophysiology remains elusive and therapeutic options are limited. Cases refractory to corticosteroid therapy pose a clinical challenge1,5 and approximately 30% of patients with DiHS/DRESS develop complications, including infections and inflammatory and autoimmune diseases1,2,5. Progress in single-cell RNA sequencing (scRNA-seq) provides an opportunity to dissect human disease pathophysiology at unprecedented resolutions6, particularly in diseases lacking animal models, such as DiHS/DRESS. We performed scRNA-seq on skin and blood from a patient with refractory DiHS/DRESS, identifying the JAK-STAT signaling pathway as a potential target. We further showed that central memory CD4+ T cells were enriched with DNA from human herpesvirus 6b. Intervention via tofacitinib enabled disease control and tapering of other immunosuppressive agents. Tofacitinib, as well as antiviral agents, suppressed culprit-induced T cell proliferation in vitro, further supporting the roles of the JAK-STAT pathway and herpesviruses in mediating the adverse drug reaction. Thus, scRNA-seq analyses guided successful therapeutic intervention in the patient with refractory DiHS/DRESS. scRNA-seq may improve our understanding of complicated human disease pathophysiology and provide an alternative approach in personalized medicine.

Publication types

  • Case Reports
  • Research Support, N.I.H., Intramural

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Adult
  • Antiviral Agents / therapeutic use
  • Autoimmune Diseases / complications
  • CD4-Positive T-Lymphocytes / cytology
  • Cell Proliferation
  • Cell Separation
  • Drug Hypersensitivity Syndrome / therapy*
  • Flow Cytometry
  • Herpesvirus 6, Human / immunology
  • Humans
  • Immunosuppressive Agents / therapeutic use
  • Leukocytes, Mononuclear / cytology
  • Lymphocytes / cytology
  • Male
  • Piperidines / therapeutic use
  • Pyrimidines / therapeutic use
  • Pyrroles / therapeutic use
  • RNA-Seq
  • Signal Transduction
  • Single-Cell Analysis*
  • T-Lymphocytes, Regulatory / cytology
  • Transcriptome*
  • VDJ Recombinases / metabolism

Substances

  • Adrenal Cortex Hormones
  • Antiviral Agents
  • Immunosuppressive Agents
  • Piperidines
  • Pyrimidines
  • Pyrroles
  • tofacitinib
  • VDJ Recombinases