Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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On Sep 2018

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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Case report
Year : 2023 | Month : January | Volume : 17 | Issue : 1 | Page : OD15 - OD17 Full Version

Pirfenidone Induced Dress Syndrome Post COVID-19 Infection-An Unusual Case Report

Published: January 1, 2023 | DOI:
Shilpi Shukla, Krushan Nirmit Yajnik, Devangi Soaham Desai, Rita Vora

1. Medicine Resident, Department of General Medicine, Shree Krishna Hospital, Karamsad, Gujarat, India. 2. Medicine Resident, Department of General Medicine, Shree Krishna Hospital, Karamsad, Gujarat, India. 3. Professor, Department of General Medicine, Shree Krishna Hospital, Karamsad, Gujarat, India. 4. Professor, Department of Dermatology, Shree Krishna Hospital, Karamsad, Gujarat, India.

Correspondence Address :
Devangi Soaham Desai,
Professor, Department of General Medicine, Shree Krishna Hospital, Karamsad, Gujarat, India.


Drug Reaction, Eosinophilia and Systemic Symptoms (DRESS) is an idiosyncratic drug reaction characterised by extensive skin rash, fever, lymphadenopathy and internal organ involvement. Since, eosinophilia may or may not always be present, the condition is now more preferably called Drug-Induced Hypersensitivity Syndrome (DIHS). The authors here report a case of DRESS syndrome, secondary to pirfenidone, an antifibrotic given to the patient for post Coronavirus Disease-2019 (COVID-19) fibrosis. The 51-years-old male patient, presented with multiple pus-filled erythematous lesions, three months after the initiation of pirfenidone. Laboratory results showed deranged liver and renal functioning, along with reactive Dengue Nonstructural protein 1(NS 1) antigen. He showed significant improvement in the dermatological lesions and multisystem laboratory involvement with tapering doses of steroids.


Coronavirus disease-2019 fibrosis, Drug induced hypersensitivity syndrome, Naranjo criteria, RegiSCAR

Case Report

A 51-year-old hypertensive male patient presented with high-grade fever, generalised weakness and anorexia of five days duration. He had a strong positive contact history with COVID-19 patients, as he was working as a social worker during the pandemic. Chest imaging High Resolution Computed Tomography (HRCT) showed multiple ground-glass opacities with diffuse irregular consolidation in bilateral lung fields (Table/Fig 1). Though, his Reverse Transcriptase-Polymerase Chain Reaction (RT-PCR) for COVID-19 was negative, but in view of strong clinical suspicion with classical radiological evidence, he was managed on the lines of COVID-19 infection using remdesevir for five days and steroids. He required 6-8 litres of oxygen during the stay, which was gradually tapered to 2 litres.

After two weeks of uneventful hospital stay, he was discharged on home-based oxygen therapy and oral steroids in tapering doses, which eventually was omitted over next four weeks. As he had persistent hypoxia requiring home oxygen treatment and his HRCT showed changes of post COVID-19 fibrosis, he was prescribed an antifibrotic agent, pirfenidone 600 mg/day. He was lost to follow-up thereafter. After three months of discharge, he presented with complains of multiple erythematous lesions over the face, trunk and extremities (Table/Fig 2). These appeared about 20 days back and gradually progressed to large, fluid and pus-filled bullous lesions, which would rupture spontaneously. He told that he continued pirfenidone since he was first released from hospital. He was readmitted for the evaluation.

During the first admission, the Liver Function Test (LFT) was within normal limits. However, during the readmission, it was significantly deranged, with raised liver enzymes, hyperbilirubinaemia, and raised creatinine levels (Table/Fig 3). Human Immunodeficiency Virus and viral hepatitis were ruled out and Antinuclear Antibody (ANA) panel was negative.

A possibility of Adverse Drug Reaction (ADR) leading to DRESS syndrome was considered. The patient was taking only steroids and pirfenidone, so pirfenidone was suspected to cause DRESS syndrome. However, in view of long-term steroids, a possibility of sepsis was also considered. As per the dermatologist’s advice, a skin biopsy from left forearm was performed from the lesion, and stained with Haematoxylin and Eosin (H&E) stain. The biopsy showed changes of atopic dermatitis favouring a drug induced reaction (Table/Fig 4). The Naranjo score was 6 implying a probable diagnosis of ADR, due to pirfenidone causing DRESS (1). Using the RegiSCAR criteria (2), a provisional diagnosis of DRESS syndrome was considered (skin eruption, fever >38ºC, visceral organ involvement-altered liver and renal function tests with eosinophilia).

Thus, pirfenidone was discontinued and injectable dexamethasone was given for three days, which later was switched to oral prednisolone. Broad spectrum antibiotics (Meropenem 1 gm intravenously three times/day) was started. Topical beclomethasone and paraffin creams were advised. After discontinuation of pirfenidone, the skin lesions started to improve over next two days. On day four of admission, he started to have fever spikes (Injection (Inj.) Meropenem 1 gm iv was ongoing, platelet count was reduced (1,71,000/μL to 1,64,000/μL). Dengue NS1 antigen was reactive. Malarial serology was negative. Dengue hepatitis was considered, but the resolution of the LFT coincided with the improvement in the skin lesions. Blood cultures showed Acinetobacter baumanii and Candida species for which antibiotics were continued according to sensitivity reports.

On follow-up, with tapering doses of oral prednisolone, he showed good recovery in both clinical and in laboratory parameters. The skin lesions regressed on subsequent follow-ups and were completely normalised over the next three months.


‘False negative’ results of COVID-19 RT-PCR, despite having a high clinical suspicion can be attributed to simple errors such as sampling errors. Also, each patient may be at a different stage of the disease spectrum when tested initially, hence giving a variable, and often unreliable result.

In patients of DRESS, there is a significant lowering of the proinflammatory cytokines viz., Tumour Necrosis Factor (TNF)-?, interferon gamma and interleukins 6, 12 (3). Various cases of DRESS syndrome have been reported with a variety of aetiologies, the most common one being drug-induced including anticonvulsant (carbamezipine), antibiotics (particularly beta-lactams), antiretrovirals and allopurinol (4). Other aetiologies include DRESS in association with the reactivation of Human Herpes Virus (HHV-6), as reported by Ichiche M et al., and also according to Lens S et al., approximately 50% of the reported cases of DRESS with hepatic involvement resulted in death or liver transplantation (5),(6).

Pirfenidone is being increasingly used for Idiopathic Pulmonary Fibrosis (IPF) as an antifibrotic agent especially for patients with mild to moderate disease, along with other anti-fibrotic drug like nintedanib. The latter is also effective in systemic sclerosis-related Interstitial Lung Disease (ILD), as well as non IPF ILD. Considering their anti-fibrotic, anti-inflammatory, oxygen radical scavenger effects (7), these drugs have been increasin gly used presuming their benefit in post COVID-19 fibrosis, especially after the first wave of COVID-19 (8).

Pirfenidone has been attributed to a variety of adverse effects like gastrointestinal (nausea, dyspepsia), neurological (insomnia, anxiety) and dermatological (rash, photosensitivity) (9). However, what is lesser known is the rare and unusual side-effects of these drugs. DRESS/DIHS is one of the very rare adverse effects of pirfenidone, which was first reported in 2018 in Japan in a patient in whom pirfenidone was given for treatment of IPF (10). However, to the best of our knowledge, this is the first case of pirfenidone induced DRESS syndrome being reported in a patient with post COVID-19 fibrosis, complicated with dengue co-infection, along with positive Widal titers.


During the current times of the pandemic, with pirfenidone being prescribed widely and routinely, such a rare and serious adverse effect should be kept in mind, and the drug should be prescribed cautiously with regular routine follow-up and looking out for such an ADR. Patients and their relatives should be counselled about possible serious adverse reactions of pirfenadone. Further, phase IV post marketing surveillance of the drug should be conducted, keeping in mind the current explosion in the aforementioned drug usage.


The authors acknowledge the assistance provided by the Intensivists, Dermatologists, Pathologists and Physicians of Pramukhswami Medical College and Shree Krishna Hospital, Anand, Gujarat, India.


Cacoub P, Musette P, Descamps V, Meyer O, Speirs C, Finzi L, et al. The DRESS syndrome: A literature review. The American Journal of Medicine. 2011;124(7):588-97. [crossref] [PubMed]
Kardaun SH, Sidoroff A, Valeyrie-Allanore L, Halevy S, Davidovici BB, Mockenhaupt M, et al. Variability in the clinical pattern of cutaneous side-effects of drugs with systemic symptoms: Does a DRESS syndrome really exist? British Journal of Dermatology. 2007;156(3):609-11. [crossref] [PubMed]
Chen YC, Chiang HH, Cho YT, Chang CY, Chen KL, Yang CW, et al. Human herpes virus reactivations and dynamic cytokine profiles in patients with cutaneous adverse drug reactions-a prospective comparative study. Allergy. 2015;70(5):568-75. [crossref] [PubMed]
Cardoso CS, Vieira AM, Oliveira AP. DRESS syndrome: A case report and literature review. Case Reports. 2011;2011:bcr0220113898. [crossref] [PubMed]
Ichiche M, Kiesch N, De Bels D. DRESS syndrome associated with HHV-6 reactivation. European Journal of Internal Medicine. 2003;14(8):498-500. [crossref] [PubMed]
Lens S, Crespo G, Carrión JA, Miquel R, Navasa M. Severe acute hepatitis in the DRESS syndrome: report of two cases. Annals of Hepatology. 2010;9(2):198-201. [crossref] [PubMed]
Fois AG, Posadino AM, Giordo R, Cossu A, Agouni A, Rizk NM, et al. Antioxidant activity mediates pirfenidone antifibrotic effects in human pulmonary vascular smooth muscle cells exposed to sera of idiopathic pulmonary fibrosis patients. Oxidative Medicine and Cellular Longevity. 2018;2018:2639081. [crossref] [PubMed]
Suda K, Kamiya K, Chiang B, Okada H, Mato N, Maekawa T, et al. A rare case of drug-induced hypersensitivity syndrome by pirfenidone for idiopathic pulmonary fibrosis. Allergology International. 2018;67(3):425-26. [crossref] [PubMed]
Jiang C, Huang H, Liu J, Wang Y, Lu Z, Xu Z. Adverse events of pirfenidone for the treatment of pulmonary fibrosis: A meta-analysis of randomized controlled trials. PLoS One. 2012;7(10):e47024. [crossref] [PubMed]
Suda K, Kamiya K, Chiang B, Okada H, Mato N, Maekawa T, et al. A rare case of drug-induced hypersensitivity syndrome by pirfenidone for idiopathic pulmonary fibrosis. Allergology International. 2018;67(3):425-26. [crossref] [PubMed]

DOI and Others

DOI: 10.7860/JCDR/2023/51554.17431

Date of Submission: Jul 27, 2021
Date of Peer Review: Nov 23, 2021
Date of Acceptance: Jan 03, 2022
Date of Publishing: Jan 01, 2023

• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

• Plagiarism X-checker: Jul 28, 2021
• Manual Googling: Jan 03, 2022
• iThenticate Software: Dec 01, 2022 (5%)

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