Dear Sir,

We read the article by Wong et al(1) with great interest. The authors noted that “While Cytomegalovirus (CMV) reactivation has been described in patients with DRESS syndrome, to our knowledge, histologically confirmed CMV hepatitis has never been described in patients with DRESS syndrome.”(1) CMV reaction has been proven to be an important inducer of drug reaction with eosinophilia and systemic symptoms (DRESS).(2) Hepatitis due to CMV reaction in DRESS syndrome is believed to be the consequence of an immune response against virus reactivation.(2) With the immunological evidence in the present case, it is questionable whether a liver biopsy should have been performed in this patient. It would appear to be an over-investigation, which might do harm to the patient. In addition, Wong et al’s case is not the first to show liver pathology confirming CMV hepatitis in DRESS. A previous report by Arakawa et al has shown that CMV involvement of visceral organs, including the liver, by histopathology study was an important finding in a fatal case of DRESS.(3)

Yours sincerely,
References
Wong YJ, Choo KJL, Soh JXJ, Tan CK.Cytomegalovirus (CMV) hepatitis: an uncommon complication of CMV reactivation in drug reaction with eosinophilia and systemic symptoms. Singapore Med J. 2018;59:112-3.
Descamps V.[Drug reaction with eosinophilia and systemic symptoms (DRESS)]. Rev Prat. 2012;62:1347-52. French.
Arakawa M, Kakuto Y, Ichikawa K, et al. Allopanol hypersensitivity syndrome associated with systemic cytomegalovirus infection and systemic bacteremia. Intern Med. 2001;40:331-5.