Acute generalized exanthematous pustulosis: report of 12 cases and literature review

Hypersensitivity Reactions to Anticonvulsants

BACKGROUND

Antiepileptics are the mainstay of treatment for seizure management. Immediate and delayed hypersensitivity reactions associated with antiepileptics are common. It is important to differentiate between these reactions as management and prognosis varies.

OBJECTIVE

This review article aims to describe the types of hypersensitivity reactions reported with antiepileptics with emphasis on delayed hypersensitivity reactions, as these can be life-threatening.

METHODS

Online databases including PubMed and Cochrane were searched, from the inception of the literature to 5/10/24. Studies focusing on hypersensitivity reactions to antiepileptics were reviewed. Case reports, case series, observational studies, and clinical trials were included. Abstracts and studies published in languages other than English were not included.

RESULTS

Immediate reactions can occur with antiepileptics however the incidence is lower than that of delayed hypersensitivity reactions. Delayed hypersensitivity reactions include benign rash as well as severe cutaneous adverse reactions. Acute generalized exanthematous pustulosis, drug rash with eosinophilia and systemic symptoms, Steven Johnson syndrome, and toxic epidermal necrolysis are discussed in detail in this review. We focused on pathogenesis, genetic predisposition, clinical presentation, treatment, and prognosis.

CONCLUSION

Severe cutaneous adverse reactions can be lethal. It is important to make the correct diagnosis and treat patients accordingly. More studies comparing therapeutic options head-to-head are needed.

Clinical characteristics, treatment and outcome of clindamycin induced acute generalized exanthematous pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a serious and rare adverse reaction to clindamycin. This study investigated the clinical features of clindamycin-induced AGEP and provided reference for the prevention and treatment of AGEP. Case reports, case series and clinical studies of clindamycin-induced AGEP were collected by retrieving English and Chinese database from inception until May 31, 2024. Of the 35 patients included, 25 (71.4%) were female, and the median age was 57 years (1.6-88 years). The duration of AGEP onset is 2 days (range 0.04,13) after initial administration. The main clinical morphology of AGEP is a non-follicular pustular on an erythematous base, which may be accompanied by fever (54.3%) and pruritus (40.0%). These lesions mainly involved extremities and trunk. The median elevated neutrophil count was 13.3 × 109/L (range 10.3, 31.4). Histologic features of AGEP are characterized by intracorneal, subcorneal, and/or intraepidermal pustules with papillary dermal edema containing neutrophilic, lymphocytic, andeosinophilic infiltrates. Patients gradually recovered after the withdrawal of clindamycin and supportive therapy with a median time of 9 days (range 2, 30). Clinicians should be aware of AGEP as a rare adverse effect of clindamycin. When clindamycin is prescribed, it should be stopped in time when AGEP occurs, and active systemic treatment should be given. AGEP is a self-limiting disease with a good prognosis.

COVID-19 presenting as acute generalized exanthematous pustulosis associated with multiorgan dysfunction in a 44-year-old female patient

Acute generalised exanthematous pustulosis (AGEP) is an unusual cutaneous reaction, most often related with a hypersensitivity reaction to commonly used drugs. It is characterized by an abrupt onset of a pustular rash within hours or days after drug exposure and usually resolves spontaneously within 1-2 weeks after drug discontinuation. Some cases associated with systemic involvement and shock have been reported. We present the case of a severe AGEP, manifesting in association with systemic involvement and haemodynamic instability resulting in shock and multiorgan dysfunction in an adult female patient diagnosed with COVID-19 infection. There were no identifiable associated drugs, and the patient was not initiated on antimalarial drugs. Our patient improved rapidly, both hemodynamically and dermatologically with no directed therapy.

Acute Generalized Exanthematous Pustulosis in an African American Male Caused by Trimethoprim-Sulfamethoxazole

Acute generalized exanthematous pustulosis (AGEP) is a rare drug-induced autoimmune disease that presents with hundreds of sterile pustules and systemic symptoms. Genetic predisposition, race, and medications prescribed are all factors in AGEP’s frequency, which occurs most commonly in Caucasians and with the use of macrolides and aminopenicillins. Cases of AGEP with sulfonamides or in African American patients are rare. To our knowledge, this is the first documented example of trimethoprim-sulfamethoxazole-induced AGEP in an African American male. In this article, we will further discuss our case and review the literature.

Photoinduced acute exanthematous pustulosis caused by dicloxacillin and exposure to sunlight

Photoinduced acute exanthematous pustulosis is a rare condition; only few cases of photo-AEP have been described previously with drugs such as norfloxacin, ciprofloxacin, and enoxacin. In this case, the reaction is seen after intake of dicloxacillin.

Acute Generalised Exanthematous Pustulosis: An Update

Acute generalised exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction and is attributed to drugs in more than 90% of cases. It is a rare disease, with an estimated incidence of 1–5 patients per million per year. The clinical manifestations characterised by the rapid development of sterile pustular lesions, fever and leucocytosis. Number of drugs has been reported to be associated with AGEP, most common being the antibiotics. Histopathologically there is intraepidermal pustules and papillary dermal oedema with neutrophilic and eosinophilic infiltrations. Systemic involvement can be present in more severe cases. Early diagnosis with withdrawal of the causative drug is the most important step in the management. Treatment includes supportive care, prevention of antibiotics and use of a potent topical steroid.

Acute generalized exanthematous pustulosis: clinical characteristics, etiologic associations, treatments, and outcomes in a series of 28 patients at Mayo Clinic, 1996-2013

BACKGROUND

Acute generalized exanthematous pustulosis (AGEP) is a rare skin condition typically caused by medications. The objective of this study was to examine the clinical features, causes, and outcomes of AGEP at a sole tertiary care center.

METHODS

A retrospective review of patients with AGEP (European Study of Severe Cutaneous Adverse Reactions score of ≥ 5) seen at Mayo Clinic (Rochester, MN, USA) between January 1, 1996, and December 31, 2013, was conducted.

RESULTS

Of 28 patients (mean age at onset: 56 years), 17 (61%) were women. The development of AGEP was attributed to medications in 25 patients (89%), with clindamycin the most common culprit (six patients). Three patients (11%) had mucous membrane involvement, and 21 (75%) showed systemic involvement. Ten patients (36%) received systemic corticosteroids for treatment of AGEP. Skin findings resolved within 15 days in 26 patients (93%) (mean time to resolution: 7.6 days). In three patients (11%), generalized skin eruptions or dermatitis developed weeks to months after the resolution of AGEP. Twenty-four patients (86%) had a personal history of drug reactions before the development of AGEP.

CONCLUSIONS

A previous history of drug reactions and clindamycin causation were more common in the present cohort than in prior reports. A small subset of patients experienced new-onset non-AGEP skin eruptions within a few months of the resolution of AGEP.

Five-Year Retrospective Review of Acute Generalized Exanthematous Pustulosis

Background. Acute generalized exanthematous pustulosis (AGEP) is an acute pustular eruption characterized by widespread nonfollicular sterile pustules. The aim of this study is to characterize the etiology, clinical features, laboratory findings, management, and outcome of patients with AGEP in Asians. Patient/Methods. A retrospective analysis was performed on patient who presented with AGEP between August 2008 and November 2012 in a tertiary center in Thailand. Results. Nineteen patients with AGEP were included. AGEP was generally distributed in seventeen patients (89.5%) and localized in two (10.5%). Fever and neutrophilia occurred in 52.6% and 68.4%, respectively. Hepatitis was found up to 26.3%. The most common etiology was drugs (94.7%), comprising of antibiotics (73.6%), proton pump inhibitors (10.5%), nonsteroidal anti-inflammatory drugs (5.3%), and herbal medicine (5.3%). Beta-lactams were the most common causal drug, particularly carbapenems and cephalosporins. This is the first report of Andrographis paniculata as an offending agent for AGEP. We found no differences between various treatment regimens (topical corticosteroid, systemic corticosteroid, and supportive treatment) regarding the time from drug cessation to pustules resolution (P = 0.171). Conclusions. We have highlighted the presentation of AGEP among Asians. We found high association with systemic drugs. Carbapenems were one of the leading culprit drugs. Finally, a localized variant was observed.

Rare case of phenytoin induced acute generalized exanthematous pustulosis with cerebellar syndrome

Acute generalized exanthematous pustulosis (AGEP) is a rare drug induced cutaneous hypersensitivity reaction characterized by sudden onset of fever with sterile pustules overlying an erythematous skin occurring all over the body. The offending drugs are usually B-lactams and macrolides. Among anticonvulsants carbamazepine and Phenobarbital are commonly associated with AGEP. Only one case of phenytoin induced AGEP has been reported in literature. We present a rare case of AGEP with cerebellar syndrome occurring after receiving loading dose of phenytoin.

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 localized exanthematous pustulosis on the face

Acute localized exanthematous pustulosis (ALEP) is a localized variant of acute generalized exanthematous pustulosis, which is characterized by the eruption of multiple scattered pustules following drug administration. A 26-year-old woman presented with multiple erythematous pustules on her face, which had appeared three days after taking antibiotics. Histopathological findings showed subcorneal pustules and mixed inflammatory cell infiltration in the dermis. The pustules were resolved within 2 weeks after the patient discontinued the antibiotics. Herein, we present a case of a woman with a cutaneous drug reaction consistent with ALEP that occurred subsequent to administration of antibiotics.

A systematic approach to systemic contact dermatitis and symmetric drug-related intertriginous and flexural exanthema (SDRIFE): a closer look at these conditions and an approach to intertriginous eruptions

Systemic contact dermatitis is a condition that occurs when an individual sensitized to a contact allergen is exposed to that same allergen or a cross-reacting molecule through a systemic route. Systemic exposure to allergens can include transcutaneous, transmucosal, oral, intravenous, intramuscular, and inhalational routes. Baboon syndrome is perhaps the most recognizable form of systemic contact dermatitis, presenting with diffuse, well demarcated erythema of the buttocks, upper inner thighs, and axillae. Other forms of systemic contact dermatitis include dermatitis at sites of previous exposure to the allergen such as at a previous site of dermatitis or at sites of previous positive patch tests, dyshidrotic hand eczema, flexural dermatitis, exanthematous rash, erythroderma, and vasculitis-like lesions. The most common causes of systemic contact dermatitis consist of three groups of allergens: (i) metals including mercury, nickel, and gold; (ii) medications including aminoglycoside antibacterials, corticosteroids, and aminophylline; and (iii) plants and herbal products including the Compositae and Anacardiaceae plant families and Balsam of Peru. Baboon syndrome caused by systemic medications without a known history of previous cutaneous sensitization in the patient has been termed drug-related baboon syndrome (DRBS) or symmetric drug-related intertriginous and flexural exanthema (SDRIFE). Criteria for SDRIFE include exposure to systemic drug at first or repeated dose, erythema of the gluteal/perianal area and/or V-shaped erythema of the inguinal area, involvement of at least one other intertriginous localization, symmetry of affected areas, and absence of systemic toxicity. The most common causes are aminopenicillins, β-lactam antibacterials, and certain chemotherapeutic agents, though the list of etiologic agents continues to grow. Baboon syndrome and SDRIFE should be strongly considered in a patient presenting with a symmetric intertriginous eruption involving multiple body folds. With the knowledge of the most frequent causes of these conditions, a detailed history and review of exposures will guide the clinician in the search for the most likely etiologic agent.

Acute generalized exanthematous pustulosis in a patient after stem cell transplantation

BACKGROUND

a severe generalized pustular eruption occurred several months after allogeneic hematopoietic stem cell transplantation for multiple myeloma in a patient being treated with antibiotics for respiratory infection. Neither he nor his donor had a history of psoriasis.

METHODS

the patient was treated with drug withdrawal and administration of cyclosporine and methylprednisolone without improvement; later, acitretin and methylprednisolone were used successfully. The eruption slowly subsided, and therapy was discontinued. Four months later, the patient experienced a recurrent severe pustular eruption associated with fever and leukocytosis, and the same treatment was used successfully again.

RESULTS AND CONCLUSION

the patient has not experienced relapses in the ensuing 3 years. Acute generalized exanthematous pustulosis is a rare cutaneous adverse reaction triggered most commonly by drugs with a tendency to resolve spontaneously. The surprisingly prolonged, refractory, and relapsing course of the eruption in our patient might be due to the immune alteration and the polypharmacologic therapy after stem cell transplantation.

Severe cutaneous adverse reactions: acute generalized exanthematous pustulosis, toxic epidermal necrolysis and Stevens-Johnson syndrome

Most drug hypersensitivity reactions show skin symptoms. The most severe cutaneous manifestations include pustular and bullous skin eruptions. These 2 manifestations can lead to acute generalized exanthematous pustulosis or Stevens-Johnson syndrome and toxic epidermal necrolysis. These complications are rare, but should be known to any doctor prescribing drugs because they are life threatening and early stoppage of treatment is mandatory.