Drug-induced acute generalized exanthematous pustulosis with positive patch tests

Clinical features, diagnosis and management of cephalosporin-induced acute generalized exanthematous pustulosis

WHAT IS KNOWN AND OBJECTIVE

Acute generalized exanthematous pustulosis (AGEP) is a serious and rare adverse reaction of cephalosporins. We aimed to describe the clinical features of cephalosporin-induced AGEP and provide a reference for rational clinical use of cephalosporins.

METHODS

We systematically searched Chinese and English databases for cephalosporin-induced TGEP-related case reports, retrospective studies, clinical studies, and review articles published before May 2022.

RESULTS AND DISCUSSION

A total of 43 patients from 35 articles were eligible, of which 28 (65.1%) were female, with a median age of 69 years. A total of 11 cephalosporins were suspected, the most commonly involved were ceftriaxone (41.9%), cephalexin (16.3%), and cefepime (9.3%). AEGP erupted primarily within 14 days after administration, manifested as nonfollicular pustules on an erythematous base, distributed favourably to the extremities (44.2%), trunk (23.3%), face (23.3%), and could involve the oral mucosa (11.6%). During AGEP resolution, the affected area had desquamation (39.5%). The acute phase of the disease may be accompanied by fever (>38.0°C) and elevated neutrophil count (>7500/mm³ ). Histology of AGEP showed subcorneal pustules (56.3%), intraepidermal cavernous pustules (37.5%), with papillary dermal edema (37.5%), containing neutrophils and eosinophilic infiltration (71.9%). After drug discontinuation, the median time to resolution of AGEP symptoms was 10 days (range 2, 90).

WHAT IS NEW AND CONCLUSION

Cephalosporin-induced AGEP is rare and should be properly diagnosed. This serious cutaneous adverse reaction is self-limiting and has a favourable prognosis, usually resolves with drug interruption, and may require additional interventions, such as topical steroids.

Results of patch testing in Acute generalized exanthematous pustulosis (AGEP): a literature review

The literature on positive patch test results in acute generalized exanthematous pustulosis (AGEP) is reviewed. 93 drugs were identified that have together caused 259 positive patch tests in 248 patients suffering from AGEP. The drug classes causing the highest number of reactions are beta-lactam antibiotics (25.9%), other antibiotics (20.8%), iodinated contrast media (7.3%) and corticosteroids (5.4%), together accounting for nearly 60% of all reactions. The highest number of reactions to individual drugs was to amoxicillin (n=36), followed by pristinamycin (n=25), diltiazem (n=14), amoxicillin-clavulanic acid (n=13), clindamycin (n=11) and iomeprol (n=8); 59 of the 93 drugs each caused a single case only. The "Top-10" drugs together caused over 50% of all reactions. The sensitivity of patch testing (percentage of positive reactions) in patients with AGEP is largely unknown, but may generally be around 50%, which also applies to pristinamycin. Patch testing in AGEP appears to be safe, although mild recurrence of AGEP skin symptoms or other rashes may occur occasionally. Clinical aspects of AGEP, including epidemiology, etiology and pathophysiology, clinical features, histology, treatment, and prognosis are briefly presented, as are diagnosing the disease and identifying the culprit drugs with patch tests, intradermal tests, in vitro tests, and challenge tests. This article is protected by copyright. All rights reserved.

Macrolide Allergic Reactions

Macrolides are antimicrobial agents that can be used to treat a variety of infections. Allergic reactions to macrolides occur infrequently but can include minor to severe cutaneous reactions as well as systemic life-threatening reactions such as anaphylaxis. Most reports of allergic reactions occurred in patients without prior exposure to a macrolide. Cross-reactivity among macrolides may occur due to the similarities in their chemical structures; however, some published literature indicates that some patients can tolerate a different macrolide. Most published reports detailed an allergic reaction to erythromycin. Desensitization protocols to clarithromycin and azithromycin have been described in the literature. The purpose of this article is to summarize macrolide-associated allergic reactions reported in published literature. An extensive literature search was conducted to identify publications linking macrolides to hypersensitivity reactions.

Patch testing in non-immediate cutaneous adverse drug reactions: value of extemporaneous patch tests

BACKGROUND

Patch testing following a standardized protocol is reliable for identifying the culprit drug in cutaneous adverse drug reactions (CADRs). However, these patch tests (PTs) require pharmaceutical material and staff, which are not always easily available.

OBJECTIVES

To evaluate an extemporaneous PT method in CADRs.

METHODS

We retrospectively analysed data for all patients referred to our department between March 2009 and June 2013 for patch testing after a non-immediate CADR. The patients who supplied their own suspected drugs were tested both with extemporaneous PTs and with conventional PTs. Extemporaneous PTs involved a nurse crushing and diluting the drug in pet. in a ratio of approximately one-third to two-thirds. Standardized PTs were performed according to guidelines, with commercial drugs diluted to 30% or with active ingredients diluted to 10%. We analysed the data for the two PT methods in terms of the number of positive test reactions, drugs tested, and type of CADR for patients in whom the two PT methods were used.

RESULTS

In total, 75 of 156 patients underwent the two PT procedures, including 91 double tests. Overall, 21 tests gave positive reactions with the two methods, and 69 other tests gave negative results with the two methods.

CONCLUSION

Our series yielded results similar to those of published series concerning the types of CADR and the drugs responsible. Our results suggest that, for CADRs, if a patient supplies a suspected drug but if the pharmaceutical material and staff are not available for conventional PTs, extemporaneous PTs performed by the nurse with the commercial drug used by the patient can be useful and reliable.

An Uncommon Side Effect of Bupropion: A Case of Acute Generalized Exanthematous Pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a rare inflammatory dermatosis characterized by multiple nonfollicular pustules that occur on erythematous skin. Despite its similarity to pustular psoriasis and association with fever and leukocytosis, AGEP typically heals quickly. Etiologically, drugs and viruses have been suspected in most cases. Here, we present a case of AGEP, in a woman, that developed 1 day after starting bupropion for smoking cessation, as a rare side effect of the treatment.

Acute Generalized Exanthematous Pustulosis in a Six-Year-Old Boy

Acute generalized exanthematous pustulosis (AGEP) presents with an abrupt onset of widespread pustules on erythematous base and rapid spontaneous healing. AGEP may have a variety of causative factors such as drugs, viral infection and exposure to mercury. We report a case of AGEP in a 6-year-old boy who presented with acute onset of fever and widespread pustular eruption on erythematous bases. Histologic examination showed neutrophilic subcorneal spongiform pustule. It is an uncommon condition in children.

Acute generalized exanthematous pustulosis caused by daptomycin in a critically ill burn victim

Acute generalized exanthematous pustulosis (AGEP) is a self-limiting type of drug eruption that frequently occurs as a reaction to antibiotics, particularly penicillins or macrolides. Daptomycin (DAP) is a newly developed antibiotic that specifically targets methicillin-resistant Staphylococcus aureus infection. We herein present the case of a 77-year-old severe burn victim who was diagnosed with DAP-induced AGEP while receiving treatment in an intensive care unit. Although rare, physicians should be aware that the administration of DAP can cause AGEP, which may complicate the clinical course of patients with a high fever and inflammation.

Acute Generalized Exanthematous Pustulosis Induced by Erlotinib (Tarceva) with Superimposed Staphylococcus aureus Skin Infection in a Pancreatic Cancer Patient: A Case Report

Acute generalized exanthematous pustulosis (AGEP) is a rare acute reaction that is drug induced in 90% of the cases and characterized by a widespread, sterile pustular rash. Erlotinib, a small-molecule EGFR tyrosine kinase inhibitor, has been approved by the FDA for patients with pancreatic cancer and non-small cell lung cancer. Skin rash is a well-known side effect related with all EGFR blocking agents. It has been suggested that rash could be used as a surrogate marker for response and possibly be associated with prolonged survival. We report a case of rare presentation of AGEP involving an adverse effect of erlotinib. The commonly reported adverse effects of erlotinib are mild skin eruptions. However, our case describes the rare presentation of AGEP induced by erlotinib. The estimated incidence rate of AGEP is approximately 1–5 cases per million/year.

Acute generalized exanthematous pustulosis caused by diltiazem

Acute generalized exanthematous pustulosis is clinically characterized by fever, pruritus and an acute pustular eruption. It can be described as having an abrupt onset and then spontaneous resolution occurs shortly after the start of symptoms, and there is usually only a single episode. Most cases have been triggered by the ingestion of drugs. Diltiazem hydrochloride is a calcium channel blocker that is commonly used for treating hypertension and angina. This drug was found to be the responsible agent in our current patient. There have been 9 such case reports in the English medical literature, yet this is the first such report in the Korean medical literature. We present the case of a 51-year-old male who experienced an acute generalized exanthematous pustulosis due to diltiazem hydrochloride and we review the relevant literature.

Ciprofloxacin-induced acute generalized exanthematous pustulosis mimicking bullous drug eruption confirmed by a positive patch test

We report the case of an 80-year-old woman presenting with ciprofloxacin-induced acute generalized exanthematous pustulosis (AGEP) confirmed by a positive patch test. Cutaneous morphology, course and histological findings were consistent with a definite diagnosis according to the AGEP validation score of the EuroSCAR study group. We point to the rarity of quinolone-induced AGEP and discuss immunological mechanisms, the value of in vivo and in vitro tests as well as the main differential diagnosis. Furthermore, we highlight in this particular case the challenging differentiation from bullous drug eruption.

Cross-Comparison of Patch Test and Lymphocyte Proliferation Responses in Patients With a History of Acute Generalized Exanthematous Pustulosis

An adverse cutaneous reaction to a systemically administered drug may rarely manifest as acute generalized exanthematous pustulosis (AGEP). Several recent reports have documented positive patch test results in patients with a history of AGEP, while two have demonstrated drug-specific in vitro lymphocyte proliferative responses. These findings suggest that drug-specific T cells mediate AGEP. We describe two patients with a history of AGEP who each demonstrated positive patch test results specific for the inciting drug: Patient #1 to the antibiotic metronidazole, and Patient #2 to the calcium channel-blocker diltiazem. Histologic examination of biopsy specimens taken from the patch test sites of these patients revealed spongiotic dermatitis and perivascular lymphocytes consistent with a delayed-type hypersensitivity reaction, rather than demonstrating subcorneal neutrophilic pustules more typical of AGEP. In vitro testing by measuring peripheral T cell proliferative responses to chemically purified drug correlated with the clinical response. In a direct cross-comparison, patch test results were shown to correlate with in vitro lymphocyte proliferative responses in two patients with a history of AGEP to different drugs. These findings provide additional evidence that the pathogenesis of AGEP involves a T cell-mediated immune response.

Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature

Cutaneous drug reactions occur with a frequency of 1-8% and can be higher for certain classes of drugs. They can range from mild morbilliform eruptions to more severe forms such as drug-hypersensitivity syndrome, toxic epidermal necrolysis or anaphylaxis. Acute generalized exanthematous pustulosis (AGEP) is considered to be a clinical reaction pattern, which is induced in over 90% of the cases by systemic drugs. It is a rare presentation of an adverse drug reaction most frequently triggered by anti-infectious drugs. A high proportion of these cases have been attributed to aminopenicillins and macrolides. We report a terbinafine-induced AGEP in a 68-year-old male confirmed by lymphocyte stimulation in vitro, and review the published cases induced by antimycotic drugs with special emphasis on terbinafine-triggered cases.

Progress in the understanding of the pathology and pathogenesis of cutaneous drug eruptions : implications for management

Cutaneous drug eruptions are among the most common adverse reactions to drug therapy. The etiology may reflect immunologic or nonimmunologic mechanisms, the former encompassing all of the classic Gell and Combs immune mechanisms. Cumulative and synergistic effects of drugs include those interactions of pharmacokinetic and pharmacodynamic factors reflecting the alteration by one drug of the effective serum concentration of another and the functions of drugs and their metabolites that interact to evoke cutaneous and systemic adverse reactions. Recent observations include the role of concurrent infection with lymphotropic viruses and drug effects that, through the enhancement of lymphoid blast transformation and/or lymphocyte survival and the contribution of intercurrent systemic connective tissue disease syndromes, promote enhanced lymphocyte longevity and the acquisition of progressively broadening autoantibody specificities. The latter are particularly opposite to drug-induced lupus erythematosus and to drug reactions in the setting of HIV infection. Specific common types of cutaneous drug eruptions will be discussed in this review. Successful management of cutaneous drug eruptions relies upon the prompt discontinuation of the causative medication; most drug eruptions have a good prognosis after this is accomplished. Oral or topical corticosteroids can be administered to aid in the resolution of some types of eruptions. Antihistamines or anti-inflammatory agents may also be administered for some eruptions.

Acute generalized exanthematous pustulosis in cystic echinococcosis: immunological characterization

We report the first case, to the best of our knowledge, of a woman suffering from cystic echinococcosis of the liver, who consequently developed urticaria and acute generalized exanthematous pustolosis (AGEP). Serum immunoglobulin (Ig)E and IgG4 specific to Echinococcus granulosus antigens were detected by immunoblotting. Furthermore, the intracellular cytokine analysis revealed a prevalent T-helper 2 polarization. It can be reasoned that, while the presence of IgE specific to various E. granulosus allergens may be responsible for the chronic urticarial manifestations, the detection of IgG4 specific for E. granulosus antigens, forming immunocomplexes, may be related to the development of the AGEP.

A case of recurrent acute generalized exanthematous pustulosis due to beta-lactam antibiotics: a case report

A case of acute generalized exanthematous pustulosis (AGEP) is presented. The case is notable for the recurrent episodes of AGEP, caused by three beta-lactam antibiotics (piperacillin, ceftazidime, and meropenem) in septicemic patient. The case represents the first report of the reaction developing in response to these three antibiotics. The report is also notable for the spontaneous resolution of the rash in all the three episodes.

Acute generalized exanthematous pustulosis induced by ingestion of bamifylline

We report a case of acute generalized exanthematous pustulosis (AGEP) in a 64-year-old woman, associated with the use of bamifylline. To the best of our knowledge there have been no previous reports of AGEP induced by the ingestion of bamifylline in the medical literature. We, therefore, add this drug to the list of causes for AGEP.

Skin manifestations of drug reactions

Dermatologic manifestations of adverse drug reactions are commonly encountered in both hospital-based and ambulatory medical practice. Diagnosis is confounded by the myriad clinical presentations associated with cutaneous drug eruptions. Some presentations are highly characteristic, while others are not as straightforward, and may simulate other primary dermatoses. In many cases, patients are utilizing several medications and an obvious temporal relationship to a specific drug is not always apparent or expressed by the patient during disclosure of his or her medical history. A thorough medication history and a high index of suspicion are very important components in the diagnosis of drug eruptions.

Allopurinol-induced pustular eruption: an unusually mild case

Pustular drug eruptions are uncommon and usually present with an acute illness. A 75-year-old-woman presented with a widespread pruritic pustular erythematous skin rash. She was otherwise well and had been commenced on allopurinol for gout 3 weeks before developing the rash. A skin biopsy was consistent with a pustular drug eruption, with features of acute generalized exanthematous pustulosis (AGEP). Allopurinol was the probable causative agent and withdrawal resulted in resolution of her eruption within 6 weeks. A diagnosis of AGEP was considered; however, this patient did not fulfil the diagnostic criteria.

Acute generalized exanthematous pustulosis (AGEP), an uncommon condition in children: case report and review of the literature

Acute generalized exanthematous pustulosis (AGEP) is characterized by acute onset of a widespread pustular eruption in association with fever. It is usually seen as a medication reaction. We describe a 17-month-old boy with AGEP secondary to exposure to amoxicillin. This is an uncommon condition in children.

Acute generalized exanthematous pustulosis associated with oral terbinafine

A case history of acute generalized exanthematous pustulosis (AGEP) following oral terbinafine is reported. A 64-year-old woman presented with a rapidly spreading micropustular eruption 3 days after completing a 28-day course of oral terbinafine. There was a positive family history of psoriasis but no personal history. The clinical presentation and histopathology were consistent with AGEP. There was nearly complete resolution of the pustular eruption within 3.5 weeks following cessation of oral terbinafine and treatment with topical and systemic corticosteroids. The patient has remained free of any recurrence 18 months later. A summary of drugs known to be associated with AGEP is presented. Prompt recognition of AGEP is stressed in order to avoid confusion with acute generalized pustular psoriasis or a systemic infection. The most important aspect of management is the immediate withdrawal of the suspect drug.

Recent advances in the pathology of cutaneous drug eruptions

Cutaneous reactions to drug therapy may be of either immunologic or nonimmunologic etiology. It is important that the dermatologist and pathologist be familiar with these types of cutaneous reactions. This article discusses the clinical features, pathogenesis, and histopathology of various cutaneous drug eruptions.

Acute generalized exanthematous pustulosis induced by salazosulfapyridine in a patient with ulcerative colitis

We report a case of acute generalized exanthematous pustulosis (AGEP) induced by salazosulfapyridine in a patient with ulcerative colitis. A 26-year-old Japanese man, who had been receiving medical attention for ulcerative colitis for one year, presented with diffuse erythema and pustules on his face and trunk, malaise, and fever up to 39 degrees C one day after the administration of salazosulfapyridine. A skin biopsy specimen disclosed intracorneal pustule composed of neutrophils and lymphohistiocytic infiltrate in the dermis. A drug lymphocyte stimulation test for salazoslufapyridine was positive, but the patch test was negative. Immunological mechanisms are suggested in the pathogenesis of psoriasis and ulcerative colitis. We suspect that a similar immunological pathway played a role in the pathogenesis of AGEP appearing in psoriasis and ulcerative colitis.

Drug eruptions in Bangkok: a 1-year study at Ramathibodi Hospital

BACKGROUND

As new drugs are introduced onto the market, it is important to determine those that can cause cutaneous reactions and with what frequency. In addition, drugs that have been used for a long period of time may cause new types of eruption that have not been observed previously. The purpose of this study was to evaluate the types of drug eruption and the causative agents in a hospital-based population for a period of 1 year.

METHODS

All in- and outpatients consulting for drug eruptions at the Dermatology Clinic, Ramathibodi Hospital from June 1995 to May 1996 were included in the study. The history and physical examination were performed by one of the authors. In suspected cases, a skin biopsy was carried out to confirm the diagnosis. Rechallenge tests with suspected drugs were performed with informed consent.

RESULTS

One hundred and thirty-two patients were enrolled in the study. The most common types of drug eruption were maculopapular eruption, fixed drug eruption, and urticaria. Antimicrobial agents were found to be the most common causative drugs, followed by antipyretic/anti-inflammatory agents and drugs acting on the central nervous system.

CONCLUSIONS

Although the most common type of drug eruption and the most common causative agents were not different from those found in previous studies, the new generation of antibiotics and antifungal agents were found to be a frequent cause of drug eruptions. New types of drug eruption, such as generalized exanthematous pustulosis and acral erythema, were observed in this study.

Drug induced acute generalized exanthematous pustulosis

A 62-year-old woman with diabetic triopathy developed widespread erythematous macules, numerous pustules, and a high fever after she underwent electric coagulation for vitreous hemorrhage. She was administered several drugs at that time. After discontinuation of the drugs, the eruption disappeared, and the fever returned to normal within two weeks. A positive patch test with isepamicin sulfate highly suggested that the symptoms described above were due to drug allergy. Cadralazine, which was positive in the drug lymphocyte stimulation test (DLST), could not be excluded from the causative drugs. A false-positive DLST with ofloxacin was confirmed by an accidental challenge test. To our knowledge, this is the first report of acute generalized exanthematous pustulosis due to isepamicin sulfate and/or cadralazine.