{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,17]],"date-time":"2026-10-17T20:39:33Z","timestamp":1792269573204,"version":"4.4.0"},"reference-count":18,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T00:00:00Z","timestamp":1788825600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Immunol."],"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Drug reaction with eosinophilia and systemic symptoms (DRESS) is a severe delayed drug hypersensitivity reaction that may overlap with secondary hemophagocytic lymphohistiocytosis (HLH). Direct antiglobulin test (DAT)-positive hemolysis during intravenous immunoglobulin (IVIG) treatment creates an attribution problem because disease-associated autoimmune hemolysis and treatment-related passive red-cell sensitization or hemolysis may present similarly.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Case presentation<\/jats:title>\n                    <jats:p>A 13-year-and-5-month-old boy developed fever and a generalized pruritic eruption following phenobarbital exposure. A point-by-point RegiSCAR assessment yielded 6 points, classifying the presentation as definite DRESS. He fulfilled five HLH-2004 criteria, consistent with secondary HLH. The patient was blood group AB and RhD-positive, received no red-cell transfusions, and received 87.5\u00a0g of IVIG (approximately 2.0 g\/kg). After 77.5\u00a0g had already been administered, dark urine was observed and DAT sampling was performed on hospital day (HD) 5 before the final 10\u00a0g IVIG infusion. Hemoglobin fell from 119 g\/L on HD 2 to 86 g\/L on HD 5 and reached 83 g\/L on HD 7; indirect bilirubin increased, and DAT was immunoglobulin G (IgG) positive (1+) and C3d negative. DAT weakened on HD 9 and became negative on HD 13. Neither pre-IVIG DAT nor red-cell antibody screening was performed, and no subsequent antibody elution or specificity testing was available. Hemolysis profiling was further limited by the absence of haptoglobin measurements, peripheral-smear assessment, cold-antibody testing, and serial reticulocyte measurements. Withdrawal of suspected drugs, high-dose methylprednisolone followed by tapering, and supportive care were followed by sustained recovery without red-cell transfusion or HLH-specific cytotoxic therapy.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>This case suggests that, in a child with definite DRESS following phenobarbital exposure and secondary HLH, DAT-positive hemolysis is temporally associated with high-dose IVIG exposure, although the underlying mechanism remains unclear. Therefore, in similar clinical scenarios, we suggest documenting blood group, pre-IVIG DAT and antibody screening, and cumulative dose prospectively.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.3389\/fimmu.2026.1907799","type":"journal-article","created":{"date-parts":[[2026,9,8]],"date-time":"2026-09-08T05:35:53Z","timestamp":1788845753000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Case Report: Definite DRESS following phenobarbital exposure with secondary HLH and DAT-positive hemolysis during high-dose IVIG treatment in a child"],"prefix":"10.3389","volume":"17","author":[{"given":"Lingmei","family":"Zhang","sequence":"first","affiliation":[{"name":"Department of Hematology, Jiangxi Provincial Children\u2019s Hospital","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Siyu","family":"Lei","sequence":"additional","affiliation":[{"name":"Jiangxi Medical College, Nanchang University","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daiyu","family":"Zhang","sequence":"additional","affiliation":[{"name":"Jiangxi Medical College, Nanchang University","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Feng","family":"Chen","sequence":"additional","affiliation":[{"name":"Department of Hematology, Jiangxi Provincial Children\u2019s Hospital","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Qian","family":"Wan","sequence":"additional","affiliation":[{"name":"Department of Hematology, Jiangxi Provincial Children\u2019s Hospital","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hong","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Hematology, Jiangxi Provincial Children\u2019s Hospital","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Zhongjin","family":"Xu","sequence":"additional","affiliation":[{"name":"Department of Hematology, Jiangxi Provincial Children\u2019s Hospital","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chongjun","family":"Wu","sequence":"additional","affiliation":[{"name":"Department of Hematology, Jiangxi Provincial Children\u2019s Hospital","place":["Nanchang, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,8]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","DOI":"10.1111\/bjd.12501","article-title":"Drug reaction with eosinophilia and systemic symptoms (DRESS): an original multisystem adverse drug reaction. 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