Risk factors for acute generalized exanthematous pustulosis (AGEP)-results of a multinational case-control study (EuroSCAR)

Drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms. Part II diagnosis and management

Drug-induced hypersensitivity syndrome, also known as drug reaction with eosinophilia and systemic symptoms, is a severe cutaneous adverse reaction characterized by an exanthem, fever, and hematologic and visceral organ involvement. The differential diagnosis includes other cutaneous adverse reactions, infections, inflammatory and autoimmune diseases, and neoplastic disorders. Three sets of diagnostic criteria have been proposed; however, consensus is lacking. The cornerstone of management is immediate discontinuation of the suspected drug culprit. Systemic corticosteroids remain first-line therapy, but the literature on steroid-sparing agents is expanding. Longitudinal evaluation for sequelae is recommended. Adjunctive tests for risk stratification and drug culprit identification remain under investigation. Part II of this continuing medical education activity begins by exploring the differential diagnosis and diagnosis of drug-induced hypersensitivity syndrome/drug reaction with eosinophilia and systemic symptoms and concludes with an evidence-based overview of evaluation and treatment.

Relationships between acute generalized eruptive pustulosis, age, sex, primary disease, and prescription medications: Further analysis of the Japanese Adverse Drug Event Report database

Background

Acute generalized eruptive pustulosis (AGEP) is a rare, but serious, drug-related adverse event. This study aimed to determine the relationships between AGEP and age, sex, primary disease, and prescription medications using a database of adverse drug events, namely, the Japanese Adverse Drug Event Report (JADER) database.

Methods

In this retrospective observational study, we analyzed AGEP reports extracted from the JADER database based on the preferred term for AGEP (code 10048799). We evaluated the effects of causative drugs, underlying diseases, age, and sex. The association between AGEP and prescription drugs was analyzed using the reporting odds ratio and adjusted for covariates using multiple logistic regression. Association rule mining was performed to evaluate the correlation between each combination of factors and AGEP.

Results

Between April 2004 and March 2023, 823,662 reports, including 869 reports on AGEP, were entered in the JADER database. The highest percentage of reports in each age group was in males aged <10 years, and clarithromycin was the most used drug in males aged <10 years. Nasopharyngitis was the most common reason for use, and Kawasaki disease was reported as a reason for use among males under 10 years of age, but not among females.

Conclusions

In boys aged <10 years, attention should be paid to the occurrence of AGEP when prescribing clarithromycin and treating Kawasaki disease.

Cross-reactivity among and between macrolides, lincosamides, and streptogramins: Study on the French pharmacovigilance database

BACKGROUND

Hypersensitivity reactions (HSR) are reported for the macrolides, lincosamides, and streptogramins (MLS) antibiotic family. Data about cross-reactivity among and between MLS remain scarce or controversial.

OBJECTIVES

The aim of this study was to provide an overview of hypersensitivity cross-reactions among MLSs based on data extracted from the French National Pharmacovigilance Database (FPVD).

METHODS

Cases of HSR to MLSs reported between January 1985 and December 2019 were extracted from the FPVD using standardized MedDRA queries (SMQ). Cases including an allergological test involving multiple MLSs and giving at least one positive result were included.

RESULTS

Of the 8394 cases reviewed, 149 were included. HSR mainly involved pristinamycin (n = 83; 53.2%) and spiramycin (n = 31; 19.9%). HSR to MLS was immediate in 54 cases and delayed in 94 cases. Skin tests represented the majority of the allergological tests performed (n = 728; 84.7%), followed by reintroduction tests (n = 79; 9.2%). Eighty-six cross-reactivities among MLS were identified in 62 cases (41.6%). All the 25 explorations performed for streptogramins showed cross-reactivities, but only 30/253 among macrolides (11.9%). Cross-reactivities between the three MLS were observed in 31/322 (9.6%) of the allergological explorations.

CONCLUSION

This study highlights the possibility of cross-reactivity among and between MLSs. Dermatologists and allergologists managing patients with HSR to MLSs should be aware of a risk of cross-reactivity among the macrolides and between the different classes of MLS and to perform MLSs allergological testing before recommending an alternative antibiotic, especially in severe drug hypersensitivity from the MLS family.

A Case of Diltiazem-Induced Pustular Rash in an 83-Year-Old Female

Acute generalized exanthematous pustulosis (AGEP) is a rare, acute skin eruption characterized by the development of numerous nonfollicular sterile pustules. Most cases are caused by drug reactions, among which Diltiazem has been incriminated. Herein, we present an 83-year-old female who presented for evaluation of generalized skin rash 3 days after initiation of Diltiazem. She was eventually diagnosed with AGEP, Diltiazem was discontinued, and systemic steroids were administered with the resolution of symptoms. This case report has the objective of encouraging clinicians to include AGEP in the differential diagnosis of skin eruption following the initiation of Diltiazem.

Cutaneous adverse drug reactions

Cutaneous adverse drug reactions (ADRs) represent a heterogeneous field including various clinical patterns without specific features suggesting drug causality. Maculopapular exanthema and urticaria are the most common types of cutaneous ADR. Serious cutaneous ADRs, which may cause permanent sequelae or have fatal outcome, may represent 2% of all cutaneous ADR and must be quickly identified to guide their management. These serious reactions include bullous manifestations (epidermal necrolysis i.e. Stevens-Johnson syndrome and toxic epidermal necrolysis), drug reaction with eosinophilia and systemic symptoms (DRESS) and acute generalized exanthematous pustulosis (AGEP). Some risk factors for developing cutaneous ADRs have been identified, including immunosuppression, autoimmunity or genetic variants. All drugs can cause cutaneous ADRs, the most commonly implicated being antibiotics (especially aminopenicillins and sulfonamides), anticonvulsants, allopurinol, antineoplastic drugs, non-steroidal anti-inflammatory drugs and iodinated contrast media. Pathophysiology is related to immediate or delayed "idiosyncratic" immunologic mechanisms, i.e., usually not related to dose, and pharmacologic/toxic mechanisms, commonly dose-dependent and/or time-dependent. If an immuno-allergic mechanism is suspected, allergological explorations (including epicutaneous patch testing and/or intradermal test) are often possible to clarify drug causality, however these have a variable sensitivity according to the drug and to the ADR type. No in vivo or in vitro test can consistently confirm the drug causality. To determine the origin of a rash, a logical approach based on clinical characteristics, chronologic factors and elimination of differential diagnosis (especially infectious etiologies) is required, completed with a literature search. Reporting to pharmacovigilance system is therefore essential both to analyze drug causality at individual level, and to contribute to knowledge of the drug at population level, especially for serious cutaneous ADRs or in cases involving newly marketed drugs.

A case report of terbinafine-induced acute generalized exanthematous pustulosis in a striking photodistributed pattern

Acute generalized exanthematous pustulosis is a rare severe cutaneous adverse reaction that classically presents in intertriginous or flexural areas and subsequently spreads diffusely across the trunk and extremities. To date, few cases of acute generalized exanthematous pustulosis arising in a photodistributed pattern are documented. Herein, we describe the second known case of photodistributed generalized exanthematous pustulosis arising in association with oral terbinafine use, providing a summary of the previously documented cases along with exploration of the potential pathophysiological mechanisms for this cutaneous reaction.

Medication Associations With Severe Cutaneous Adverse Reactions: A Case/Non-Case Analysis Using the FDA Adverse Event Reporting System

BACKGROUND

Stevens-Johnson syndrome (SJS), toxic epidermal necrolysis (TEN), drug reaction with eosinophilia and systemic symptoms (DRESS), and acute generalized exanthematous pustulosis (AGEP) are potentially life-threatening severe cutaneous adverse reactions (SCARs). Although the classical causal agents of SCARs (antibiotics, anticonvulsants, nonsteroidal anti-inflammatory drugs, and allopurinol) are well characterized, there has been little update to this list to account for newly marketed medications.

OBJECTIVE

To provide an updated and stratified list of medications with significant reporting odds ratios (RORs) of SCARs.

METHODS

A case/non-case analysis using the United States FDA Adverse Event Reporting System was performed.

RESULTS

As expected, the prototypical medication classes made up the majority of reported cases of SJS, TEN, AGEP, and DRESS (77%, 64%, 75%, and 72%, respectively). In addition, several infrequently or previously undescribed classes/medications implicated in SCARs were identified to have significant ROR signals, including acetylcysteine, anticoagulants, diuretics, immunotherapies, proton pump inhibitors, antivirals, and antifungals. Among these reported for SJS were acetylcysteine (ROR: 64.38) and fluconazole (ROR: 17.13). For TEN, we identified furosemide (ROR: 26.32), spironolactone (ROR: 14.45), fluconazole (ROR: 30.21), amphotericin B (39.06), and acetylcysteine (ROR: 93.12). For AGEP, we identified acyclovir (ROR: 61.72), valacyclovir (ROR: 30.76), and enoxaparin (ROR: 27.37). For DRESS, we identified vemurafenib (ROR: 17.35), acyclovir (ROR: 30.63), abacavir (ROR: 26.62), raltegravir (ROR: 23.27), and valacyclovir (ROR: 21.77) to have strong reporting odds.

CONCLUSION

Our analysis provides an updated tool for physicians to reference when identifying suspected SCARs and a basis for future studies to investigate atypical medication causality.

Paracetamol (Acetaminophen)-associated SJS, TEN, AGEP, and DRESS Syndromes - A Narrative Review

INTRODUCTION

Paracetamol (Acetaminophen) is a very common OTC drug that is found in more than 200 OTC products sold as pain, cough and cold remedies. Paracetamol is commonly used as an antipyretic to reduce fever and as an alternative to Non-steroidal anti-inflammatory drugs (NSAIDs) that are contraindicated in certain patients to relieve mild-moderate pain.

OBJECTIVE

This review article focuses on SJS, TEN, SJS/TEN overlap, AGEP, and DRESS syndromes associated with the use of paracetamol or paracetamol-containing products.

METHODS

To find published articles relevant to paracetamol-associated SJS, TEN, AGEP, and DRESS, we searched the online databases Medline/Pubmed/PMC, Google Scholar, Science Direct, Ebsco, Scopus, Web of Science, Embase, and reference lists using keywords like Stevens-Johnson Syndrome, Acetaminophen, Paracetamol, Toxic epidermal necrolysis, Acute generalized exanthematous pustulosis, Drug reaction with eosinophilia and systemic symptoms.

RESULTS

The paracetamol-associated SJS, TEN, SJS/TEN overlap, AGEP, and DRESS syndromes have been identified by a number of publications.

CONCLUSION

When evaluating drug-induced hypersensitivity skin reactions, healthcare professionals, including prescribers, pharmacists, and others, should be aware of this rare risk. Patients who exhibit signs and symptoms of paracetamol-associated hypersensitivity should be referred to physicians by pharmacists for further treatment. At the first sign of a skin rash or other hypersensitivity reaction while taking paracetamol, patients should be told to stop taking it and see a doctor right away.

Acute generalized exanthematous pustulosis: Analysis of cases managed in a Tunisian tertiary hospital

Acute generalized exanthematous pustulosis (AGEP) is a severe and life-threatening cutaneous adverse reaction. Drug-induced AGEP is mainly related to antibiotics. More recently, AGEP following spider bites has been increasingly described. Treatment includes withdrawal of the offending drug and supportive care. In Tunisia, data concerning severe cutaneous adverse reactions (SCARs) in general and especially AGEP is lacking. Herein, we conducted a retrospective study to investigate the epidemiological, clinical characteristics and etiologies of AGEP referred to the Dermatology department. Our study included 32 cases of AGEP. AGEP cases occurred in overall 8.9% of all SCARs referred to the department during the same period study. The majority were females (24 women and 7 men). The median age of the patients was 33 years. A history of psoriasis was reported in 16.1% of patients. All patients presented with an extensive erythematous rash with pinhead pustules. Neutrophil hyperleukocytosis (greater than 7000/mm3) was noted in 17 patients (63% of cases). It was associated with hypereosinophilia exceeding 500 elements/mm3 in 8 cases (29.6%). Drug-induced AGEP was reported in 53% of cases. Antibiotics were implicated in the majority of cases. Delay in onset ranged from 15hours to 7 days, with an average of 2.8 days. A non-drug-induced etiology was considered if the pharmacological investigation was negative, or if a clear non-drug trigger was found. It was retained in ten cases (48.4% of all observations). Spider bites were revealed in 8 cases. AGEP represents a severe, usually drug-related skin reaction. It is classified as a type IVd reaction mediating T cell-related sterile neutrophilic inflammatory response. It typically occurs within 24-48 h of ingestion of the offending drug. Antibiotics are the most common drug family to cause AGEP. Spider bites were involved in 25.8% of cases in our study, as important as antibiotic-induced AGEP. Analysis of the particularities of AGEP according to etiology, whether drug-induced or not, revealed the presence of an initial escarotic lesion (P=0.01) and the finding of blood hypereosinophilia (P=0.014) in the non-drug AGEP group were the distinguishing features. Blood hyperesoniophilia, more frequent in the non-drug AGEP group, suggests a pathophysiology probably different from that of the drug AGEP group. Clinicians should be aware of both etiologies. Our study focuses on the importance of AGEP associated with spider bite as a potential triggering factor in Tunisia.

Severe cutaneous adverse reactions due to antibiotics therapy: a pharmacovigilance analysis of FDA adverse event reporting system events

BACKGROUND

The aim of this study was to monitor, identify and evaluate severe cutaneous adverse reactions (SCAR) induced by antibiotics in patients.

METHODS

Disproportionality algorithms were performed in data mining to screen suspected SCAR after using nine categories of antibiotics based on the FDA's Adverse Event Reporting System (FAERS) from January 2004 to December 2022. The drug information and demographic characteristics of antibiotic-associated SCAR were also investigated.

RESULTS

The FAERS database received 12,212 antibiotic-associated SCAR cases. Approximately half of the SCAR patients were females, the majority of them were adults aged 18-65 years (48.35%), and 47.68% of SCAR patients required hospitalization. The highest SCAR signals RORs (95% CI) for antibiotics were: sulfonamides 23.30 (22.05-24.62), glycopeptides 21.27 (20.26-22.33), penicillins 16.00 (15.44-16.59), carbapenems 10.46 (9.57-11.44), and cephalosporins 13.27 (12.57-14.00). Cefotaxime, sulfamethoxazole/trimethoprim, cefixime, vancomycin, piperacillin, ceftriaxone, amoxicillin, and meropenem had stronger associations with the SCAR than the other antibiotics. However, sulfonamides-associated SCAR cases had the lowest fatality rate (6.23%), penicillin-associated SCAR cases had the highest hospitalization rate (54.16%), and carbapenem-associated SCAR cases seemingly resulted in the highest risk of death (19.03%).

CONCLUSION

Data mining of FAERS identified 30 antibiotic-associated SCAR signals, and provided a referable evidence of the occurrence, characteristics and prognosis of antibiotic-related SCARs.

Concurrent acute generalized exanthematous pustulosis in siblings

Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse reaction triggered in most cases by drugs. It is characterized by abrupt onset and rapid evolution of fields of sterile pustules on an erythematous background. The role of genetic predisposition in this reactive disorder is being explored. We report the simultaneous occurrence of AGEP in two siblings after being exposed to the same drug.

Drug Hypersensitivity Reactions

Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.

Acute Generalized Exanthematous Pustulosis: Clinical Features, Differential Diagnosis, and Management

Acute generalized exanthematous pustulosis (AGEP) is a rare, acute, severe cutaneous adverse reaction mainly attributed to drugs, although other triggers, including infections, vaccinations, ingestion of various substances, and spider bites, have also been described. AGEP is characterized by the development of edema and erythema followed by the eruption of multiple punctate, non-follicular, sterile pustules and subsequent desquamation. AGEP typically has a rapid onset and prompt resolution within a few weeks. The differential diagnoses for AGEP are broad and include infectious, inflammatory, and drug-induced etiologies. Diagnosis of AGEP depends on both clinical and histologic criteria, as cases of overlap with other disease processes have been reported. Management includes removal of the offending drug or treatment of the underlying cause, if necessary, and supportive care, as AGEP is a self-limited disease. This review aims to provide an overview and update on the epidemiology, pathogenesis, reported precipitating factors, differentials, diagnosis, and management of AGEP.

Clinical features of acute generalized exanthematous pustulosis caused by hydroxychloroquine in rheumatology patients and exploration of CARD14 gene mutations

Introduction

Acute generalized exanthematous pustulosis (AGEP) is a rare condition characterized by superficial pustules following drug ingestion or infection. Currently, there is no clear link between rheumatism and AGEP. It has been described that hydroxychloroquine (HCQ) is a rare cause of acute generalized epidermal necrolysis (AGEP). Presently, there are limited studies on HCQ-induced AGEP. We aimed to explore the clinical features and associated gene expression of AGEP induced after HCQ treatment exposure in rheumatology patients.

Methods

We assessed patients with HCQ-induced AGEP diagnosed at the Second Affiliated Hospital of Guizhou University of Chinese Medicine between January 1, 2017, and May 1, 2022. We also reviewed similar cases reported in specific databases.

Results

The study included five females (mean age, 40.2 years), and the mean time from initiation of HCQ treatment to symptom onset was 12.2 d. All patients received steroids and allergy medications after HCQ discontinuation, and the rash completely resolved within an average of 25.2 d. We performed whole exome sequencing and Sanger validation in our patient sample. CARD14 gene mutations were detected in three patients. Additionally, seven mutation sites were detected.

Discussion

HCQ-induced AGEP may have a longer latency period and regression time than AGEP induced by other drugs. Our patients all experienced CARD14 gene mutations. AGEP often resolves with topical therapy and drug discontinuation, although some cases require systemic steroid therapy. In the future, patients with rheumatism should pay attention to the effectiveness of HCQ during treatment and be aware of the associated skin toxicity.

Epidemiology, clinical presentation, and outcomes of 620 patients with eosinophilia in the intensive care unit

PURPOSE

Although eosinophil-induced manifestations can be life-threatening, studies focusing on the epidemiology and clinical manifestations of eosinophilia in the intensive care unit (ICU) are lacking.

METHODS

A retrospective, national, multicenter (14 centers) cohort study over 6 years of adult patients who presented with eosinophilia ≥ 1 × 10⁹/L on two blood samples performed from the day before admission to the last day of an ICU stay.

RESULTS

620 patients (0.9% of all ICU hospitalizations) were included: 40% with early eosinophilia (within the first 24 h of ICU admission, ICU-Eo1 group) and 56% with delayed (> 24 h after ICU admission, ICU-Eo2 group) eosinophilia. In ICU-Eo1, eosinophilia was mostly due to respiratory (14.9%) and hematological (25.8%) conditions, frequently symptomatic (58.1%, mainly respiratory and cardiovascular manifestations) requiring systemic corticosteroids in 32.2% of cases. In ICU-Eo2, eosinophil-related organ involvement was rare (25%), and eosinophilia was mostly drug-induced (46.8%). Survival rates at day 60 (D60) after ICU admission were 21.4% and 17.2% (p = 0.219) in ICU-Eo1 and ICU-Eo2 patients, respectively. For ICU-Eo1 patients, in multivariate analysis, risk factors for death at D60 were current immunosuppressant therapy at ICU admission, eosinophilia of onco-hematological origin and the use of vasopressors at ICU admission, whereas older age and the use of vasopressors or mechanical ventilation at the onset of eosinophilia were associated with a poorer prognosis for ICU-Eo2 patients.

CONCLUSION

Eosinophilia ≥ 1 × 10⁹/L is not uncommon in the ICU. According to the timing of eosinophilia, two subsets of patients requiring different etiological workups and management can be distinguished.

Patient Care Outcomes in Hospitalized Patients with Acute Generalized Exanthematous Pustulosis: A Cross-Sectional Database Study

BACKGROUND

Current understanding of the etiology, natural history, and outcomes of acute generalized exanthematous pustulosis (AGEP) has been limited, with most available studies consisting of small or heterogenous cohorts.

OBJECTIVES

The aim of this study was to further characterize associated factors and disease outcomes of AGEP.

METHODS

A cross-sectional study design was employed with formal inclusion and causality criteria. Patients were identified from an inpatient database at an academic medical center, including 65 patients with AGEP and a control group of 61 patients with non-severe cutaneous adverse reactions.

RESULTS

Increased age and body mass index (BMI) were associated with higher risk of AGEP (p < 0.001). Length of stay was longer for both the overall AGEP cohort (13.1 days) and a subcohort with a primary discharge diagnosis of AGEP (9.7 days) compared with the control group (3.6 days) [p < 0.001]. Patients with AGEP were more likely to be discharged to a long-term care facility compared with control patients (p < 0.001).

CONCLUSIONS

AGEP was associated with longer length of hospitalization, higher rates of discharge to long-term care facilities, and higher mortality compared with non-severe cutaneous adverse drug reaction (SCAR) medication reactions. Future research should examine the association between morbid obesity and this particular drug reaction, and the possibility of decreasing hospitalization length given the relatively low risk of mortality among patients with AGEP.

Clinical Manifestations and Management of Terbinafine-Induced Acute Generalized Exanthematous Pustulosis

Background. Acute generalized exanthematous pustulosis (AGEP) is a rare and serious adverse reaction of terbinafine. Understanding AGEP and terbinafine is primarily based on case reports. The purpose is to explore the clinical characteristics of terbinafine-induced AGEP, and to provide reference for clinical diagnosis and treatment. Methods. Case reports and original studies of terbinafine-induced AGEP were retrieved by searching Chinese and English databases from January, 1991, to May 31, 2022. Results. The median age of the 32 patients (17 males and 15 females) was 55 years (range: 6–84). The median time to onset of AGEP is 8 days (range: 1–77) and is usually accompanied by fever (>38°C) and elevated neutrophil levels (>8000/mm3). Four patients (12.5%) had oral mucosal involvement, and 10 patients (31.3%) developed postpustular desquamation. The lesions were mainly distributed in the trunk (43.8%), the whole body (34.4%), and the extremities (53.1%). Skin biopsy revealed subcorneal pustules (65.6%), intraepidermal cavernous pustules (43.8%), necrotic keratinocytes (15.6%), spongy hyperplasia (25.0%), neutrophil exocytosis (34.4%), and papillary dermal edema (40.6%). AGEP resolved completely in all patients at a median time of 12 days (range: 2–90) after discontinuation of terbinafine and symptomatic therapy. Conclusion. Clinicians should be aware that terbinafine-induced AGEP is a rare cutaneous adverse reaction. AGEP usually occurs within 2 weeks after administration and has a good prognosis after discontinuation.

Skin testing as a biomarker in drug allergy

Despite the significant negative impact drug allergies can have on patient care, the diagnosis is largely based on clinical history, and there are limited diagnostic tests that can be done at the time of a reaction. Biomarkers are needed to improve the diagnosis and the identification of the culprit medication. Skin testing is the most useful biomarker for immediate- and delayed-type reactions available, but it is limited by its low sensitivity. To improve its accuracy and reproducibility, a standardized procedure must be used. For immediate-type reactions, penicillin skin testing is the most widely studied, and it can be used in patients with history of anaphylaxis or recent immunoglobulin E-mediated reaction or for whom there is a significant risk if a reaction were to occur, such as pregnancy. Skin testing is also important in allergy to platinum agents allowing for continued first-line therapy. For delayed-type reactions, patch testing and delayed intradermal testing, used in conjunction with clinical history, can help to improve identification of the culprit medication depending on the type of reaction. Other biomarkers including in vitro testing for specific immunoglobulin E, basophil activation test, lymphocyte transformation test, ELISpot, and genetic factors that increase the likelihood of reaction are under investigation, and they may be most helpful when used in combination with the clinical history and skin testing results.

Acute Localized Exanthematous Pustulosis (ALEP) Caused by Topical Application of Minoxidil

Acute Localized Exanthematous Pustulosis (ALEP) is a rare skin reaction characterized by the sudden onset of multiple, small, sterile, non-follicular pustules in an erythematous and edematous base succeeding systemic drug administration. ALEP is considered a subtype of Acute Generalized Exanthematous Pustulosis (AGEP), although the exact pathogenic mechanism of the disease remains poorly defined. Numerous drugs have been implicated in the pathogenesis of ALEP, while contact mechanisms have also been reported. Herein, we describe the first case of ALEP attributed to minoxidil in a female patient with androgenetic alopecia. The positivity of patch tests and the topical application of minoxidil proposes a contact-induced hypersensitivity reaction. Identifying new agents-including minoxidil-which serve as inducers of drug-specific T-cell-mediated responses in the clinical spectrum of ALEP, adds further value in understanding the complex, yet unknown, pathophysiological mechanisms of this rare drug hypersensitivity reaction.

Terbinafine Induced Acute Generalized Exanthematous Pustulosis Treated with Adalimumab: Recalcitrant to Systemic Corticosteroid Therapy

Acute generalized exanthematous pustulosis (AGEP) is generally caused by drugs and is characterized by the rapid development of numerous non-follicular sterile pustules on an erythematous base, fever, and neutrophilia. We report an association between terbinafine, with AGEP, and adalimumab treatment. A 24-year-old teenage female patient with a history of onychomycosis was treated with terbinafine. On the second day of the first dose, multiple edematous and erythematous lesions appear with pinhead pustules. Neutrophilia was observed in the blood report. The clinical history, lesions, and laboratory evaluations were consistent with AGEP. We discontinued the terbinafine therapy, and the systemic corticosteroid was initiated; however, the patient's condition worsened. Adalimumab subcutaneously was initiated, and the symptoms cleared up in weeks. The European Study of Severe Cutaneous Adverse Reactions (EuroSCAR) scoring system and Naranjo's algorithm scale were used to check the possibility of a drug-induced adverse reaction. The Association of AGEP with the terbinafine drug is not rare. However, there are no reports or literature of drug-related rash or exanthematous eruptions unresponsive to corticosteroids and treated with adalimumab.

A case report of rheumatoid neutrophilic dermatitis in a Chinese woman with seropositive rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory arthritis associated with a number of extra-articular manifestations. We report the case of a rare extra-articular manifestation of seropositive RA in a 48-year-old woman. She developed spontaneously remitting pustular rashes on the dorsum of both hands which recurred during periods of a high disease activity. Skin biopsy revealed rheumatoid neutrophilic dermatosis (RND), a rare skin manifestation of RA. Both RA and RND were controlled with rituximab therapy. Clinical presentations and differential diagnoses were discussed. Tight control of RA is pivotal in the management of RA and extra-articular manifestations.

Tools to improve the diagnosis and management of T-cell mediated adverse drug reactions

Delayed drug T-cell immune-mediated hypersensitivity reactions have a large clinical heterogeneity varying from mild maculopapular exanthema (MPE) to severe cutaneous adverse reactions (SCARs) such as acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS) and severe skin necrosis and blistering as seen in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). Given the knowledge gaps related to the immunopathogenesis of these conditions, the absence of validated diagnostic tools and the significant associated morbidity and mortality, patients with SCARs often have limited drug choices. We performed a comprehensive review aiming to evaluate in vivo diagnostic tools such as delayed intradermal skin and patch testing and ex vivo/in vitro research assays such as the lymphocyte transformation test (LTT) and the enzyme-linked ImmunoSpot (ELISpot) assay. We searched through PubMed using the terms “drug allergy,” “in vivo” and “ex vivo” for original papers in the last 10 years. A detailed meticulous approach adapted to the various clinical phenotypes is recommended for the diagnostic and management of delayed drug hypersensitivity reactions. This review highlights the current diagnostic tools for the delayed drug hypersensitivity phenotypes.

Annular drug eruptions

Cutaneous adverse drug reactions are undesirable cutaneous changes caused by medications. Drug eruptions can mimic a wide range of dermatoses that include exanthematous (morbilliform), urticarial, pustular, bullous, papulosquamous, or granulomatous lesions, and sometimes these eruptions may present with annular, polycyclic, or polymorphous configurations. The correct identification of a cutaneous drug eruption depends on a high index of suspicion, detailed medication exposure history, chronologic evaluation of the causal relationships between drug exposures and eruptions, and the exclusion of other infectious or idiopathic diseases. Most drug eruptions are annoying but self-limited, usually resolving after the withdrawal of the causative agents. Rarely, patients have severe cutaneous adverse reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, and drug reaction with eosinophilia and systemic symptoms (DRESS), which are potentially lethal adverse drug reactions that involve the skin and mucous membranes and may also damage internal organs. Prompt recognition of the alarming signs of severe cutaneous adverse reactions and providing adequate treatment may thus be life-saving. We present the main clinical presentations, histopathology, possible implicated medications, and treatment of cutaneous adverse drug reactions that can present in annular configurations.

Acute Generalized Exanthematous Pustulosis following SARS-CoV-2 Virus: Remdesivir as a Suspected Culprit

Acute generalized exanthematous pustulosis (AGEP) is an exanthematous condition, predominantly occurring as a result of drug reactions. We, hereby, present the first case of AGEP following treatment with remdesivir in a patient with COVID-19, without hydroxychloroquine use, which serves as a reminder to consider remdesivir as a possible causative agent when dealing with AGEP presentation in COVID patients.

What to expect when AGEP is induced by terbinafine? case report and critical review of the literature

BACKGROUND

Acute Generalized Exanthematous Pustulosis (AGEP) is a rash with multiple sterile intraepidermal or sub corneal non-follicular pustules on edematous papules, with a sudden development and rapid evolution, triggered by drugs, vaccination, insect bites, exposure to mercury and allergens.

OBJECTIVES AND METHODS

We describe a female patient who developed extensive and abnormally prolonged AGEP following exposure to terbinafine and Sars-COV Vaccine. A detailed review of terbinafine-induced-AGEP cases was performed, with the aim of evaluating if the AGEP criteria would follow a different pattern when the disease is triggered by this drug. A pubmed search helped retrieve all terbinafine induced AGEP case reports. AGEP specific Sideroff criteria were analyzed in Terbinafine-induced cases, and compared to other trigger causes.

CONCLUSIONS

when AGEP causative drug was terbinafine, a delay in recovery was observed, compared to the existing AGEP criteria when other causes are considered. Terbinafine frequently leads to delayed resolution AGEP probably due to the presence of the drug in the skin during several weeks after exposure, even after discontinuation, and the disease severity may be potentialized by additional factors such as concomitant viral infections or vaccination.

Generalized pustular psoriasis: overview of the status quo and results of a panel discussion

Generalized pustular psoriasis (GPP) is a rare, severe, potentially life-threatening, autoinflammatory, neutrophilic skin disease that may be accompanied by fever and leukocytosis. This paper describes the current state of knowledge on GPP in terms of classification, (differential) diagnosis and prevalence. We present a comparison of the genetics and pathoimmunology of GPP and psoriasis vulgaris with the central mechanisms of autoimmunology and autoinflammation. The currently available therapeutic options, expert recommendations for therapy, and data from early clinical trials investigating targeted therapies will be summarized. We present the results of our discussion with 13 experts for psoriasis vulgaris and GPP and give an integrated overview of indication and therapy based on our personal experience and present an outlook on further research questions. Collectively, this article highlights the high unmet need in GPP, as there exists no satisfactory method of diagnosis or treatment to date and new treatment options will be of great therapeutic benefit to those affected.

Safety of Short-Term Treatments with Oral Chloroquine and Hydroxychloroquine in Patients with and without COVID-19: A Systematic Review

Chloroquine (CQ) and hydroxychloroquine (HCQ) have recently become the focus of global attention as possible treatments for Coronavirus Disease 2019 (COVID-19). The current systematic review aims to assess their safety in short treatments (≤14 days), whether used alone or in combination with other drugs. Following the PRISMA and SWiM recommendations, a search was conducted using four health databases for all relevant English-, Chinese-, and Spanish-language studies from inception through 30 July 2021. Patients treated for any condition and with any comparator were included. The outcomes of interest were early drug adverse effects and their frequency. A total of 254 articles met the inclusion criteria, including case and case-control reports as well as cross-sectional, cohort, and randomised studies. The results were summarised either qualitatively in table or narrative form or, when possible (99 studies), quantitatively in terms of adverse event frequencies. Quality evaluation was conducted using the CARE, STROBE, and JADAD tools. This systematic review showed that safety depended on drug indication. In COVID-19 patients, cardiac adverse effects, such as corrected QT interval prolongation, were relatively frequent (0–27.3% and up to 33% if combined with azithromycin), though the risk of torsade de pointes was low. Compared to non-COVID-19 patients, COVID-19 patients experienced a higher frequency of cardiac adverse effects regardless of the regimen used. Dermatological adverse effects affected 0–10% of patients with autoimmune diseases and COVID-19. A broad spectrum of neuropsychiatric adverse effects affected patients treated with CQ for malaria with variable frequencies and some cases were reported in COVID-19 patients. Gastrointestinal adverse effects occurred regardless of drug indication affecting 0–50% of patients. In conclusion, CQ and HCQ are two safe drugs widely used in the treatment of malaria and autoimmune diseases. However, recent findings on their cardiac and neuropsychiatric adverse effects should be considered if these drugs were to be proposed as antivirals again.

Skin manifestations in patients with coronavirus disease 2019

PURPOSE OF REVIEW

Coronavirus disease 2019 (COVID-19) is a well established respiratory tract illness. Recent studies in adults and children have shown an increasing number of patients reporting polymorphic cutaneous manifestations during COVID-19, including different types of rashes, from maculopapular, vascular, vesicular to atypical forms.

RECENT FINDINGS

Although pathogenesis of skin manifestations is still not fully understood, it has been proposed that cutaneous involvement during COVID-19 may be the results of the activation of the immune response against severe acute respiratory syndrome coronavirus-2, the reactivation or co-infection of herpesviruses or drug hypersensitivity.

SUMMARY

According to available literature, skin manifestations in patients with COVID-19 may be categorized on the basis of their clinical presentations as follows: erythematous rashes, lesions of vascular origin, vesicular rash, urticarial rash and acute generalized exanthematous pustulosis (AGEP), erythema multiforme and other polymorphic erythema/atypical reactions. Prompt recognition of these cutaneous manifestations represents a crucial point to facilitate diagnosis and management of COVID-19 patients.

Multisystem organ failure secondary to acute generalised exanthematous pustulosis (AGEP) with atypical presentation resembling septic shock

A woman was admitted for sepsis secondary to cellulitis. After clinical improvement of sepsis, non-follicular small pustules were observed on the trunk, limbs and face while vesicles/bullae and skin exfoliation were noted on upper extremities. Larger systemic manifestations included fever, hypertension and tachycardia. Laboratory results revealed neutrophilic leukocytosis, eosinophilia, mild transaminitis and acute renal failure. Despite treatment for potential sepsis and discontinuation of offending agents, her condition worsened leading to haemodynamic instability and renal failure requiring vasopressor support, intubation and continuous veno-venous haemodialysis. Skin biopsy revealed a diagnosis of acute generalised exanthematous pustulosis (AGEP), a rare condition usually caused by antibiotic treatment. The suspected offending drug was clindamycin, with possible combined effects by metronidazole and/or vancomycin. Improvement of skin manifestations were seen within 48 hours of starting systemic steroids. Here, we present an uncharacteristic case of AGEP clinically presenting with atypical skin lesions, severe systemic involvement mimicking septic shock, which culminated in multisystem organ failure.

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.

Exanthematous Drug Eruption to Intravenous Iron: A Case Report

The authors present a rare case of an exanthematous drug reaction to intravenous iron. Exanthematous drug eruptions, also called morbilliform or maculopapular drug rashes, can occur in first-time drug exposures and represent a subtype of delayed-type IV hypersensitivity reactions. 

This patient is a 49-year-old female with a history of iron deficiency anemia and hypothyroidism who presented to the emergency department after experiencing a diffuse whole-body maculopapular rash following ferumoxytol 510 mg intravenously received once two days prior to her presentation. A clinical examination was suspicious of an exanthematous drug eruption. The patient was treated with methylprednisolone 40 mg intravenously twice a day for three days, followed by prednisone 40 mg orally twice a day for two days with a steroid taper upon discharge. The patient’s rash resolved within five days of steroid treatment.

There is a high global prevalence of iron deficiency anemia for which intravenous iron replacement may be required. However, there is limited research addressing its adverse effects, particularly those that include delayed hypersensitivity reactions. This paper aims to alert healthcare professionals of a rare type of delayed hypersensitivity reaction to intravenous iron to better guide management in the clinical setting. 

The important role of non-covalent drug-protein interactions in drug hypersensitivity reactions

Drug hypersensitivity reactions (DHR) are heterogeneous and unusual immune reactions with rather unique clinical presentations. Accumulating evidence indicates that certain non‐covalent drug‐protein interactions are able to elicit exclusively effector functions of antibody reactions or complete T‐cell reactions which contribute substantially to DHR. Here, we discuss three key interactions; (a) mimicry: whereby soluble, non‐covalent drug‐protein complexes (“fake antigens”) mimic covalent drug‐protein adducts; (b) increased antibody affinity: for example, in quinine‐type immune thrombocytopenia where the drug gets trapped between antibody and membrane‐bound glycoprotein; and (c) p‐i‐stimulation: where naïve and memory T cells are activated by direct binding of drugs to the human leukocyte antigen and/or T‐cell receptors. This transient drug‐immune receptor interaction initiates a polyclonal T‐cell response with mild‐to‐severe DHR symptoms. Notable complications arising from p‐i DHR can include viral reactivations, autoimmunity, and multiple drug hypersensitivity. In conclusion, DHR is characterized by abnormal immune stimulation driven by non‐covalent drug‐protein interactions. This contrasts DHR from “normal” immunity, which relies on antigen‐formation by covalent hapten‐protein adducts and predominantly results in asymptomatic immunity.

Drug Triggers and Clinic of Acute Generalized Exanthematous Pustulosis (AGEP): A Literature Case Series of 297 Patients

Acute generalized exanthematous pustulosis (AGEP) is a rare skin reaction, commonly caused by drugs. Available evidence mostly relies on small studies or case reports. We collected published AGEP case reports and, subsequently, described the patient characteristics, suspect and concomitant drugs, time to onset, disease management, and clinical prognosis. This study included 297 AGEP patients (64.3% women) obtained from 250 published case reports or case series with individual patient data. AGEP affected patients of all ages, but the majority of patients (88.2%) were ≥25 years old. The most frequently reported suspect drugs were anti-infectives for systemic use (36.5%), particularly antibacterials for systemic use (31.0%), and especially beta-lactam antibacterials (18.3%) and macrolides (4.3%). Other frequent suspect drugs were antineoplastics (12.2%), and anti-inflammatory/anti-rheumatic products (5.2%) plus hydroxychloroquine (12.8%). Mean time to onset was 9.1 days (standard deviation SD 13.94). Some patients developed fever (64.3%) and systemic involvement (18.9%), and most patients (76.4%) received pharmacological treatment for AGEP. Seven patients died, although five of them were already critically ill prior to AGEP. In conclusion, antibiotics remain the most common suspected cause of AGEP. While case mortality rate may be up to 2.5%, disentangling the role of AGEP on the fatal outcome from the role of the preexisting health conditions remains challenging.

Acute localized exanthematous pustulosis because of cefixime in a child: case report and review of pediatric cases

BACKGROUND

Acute localized exanthematous pustulosis (ALEP), a localized variant of acute generalized exanthematous pustulosis, is characterized by pin-sized, non-follicular, sterile pustules that typically appear on the face, neck, and chest.

OBJECTIVE

The purpose of this report is to describe a case of ALEP in an 11-year-old girl because of cefixime and the etiological factors and clinical presentation of ALEP in pediatric group.

METHODS

We described a case of ALEP in an 11-year-old girl because of cefixime; a systematic review of the literature was performed to identify the etiological factors and clinical presentation of ALEP in children.

RESULTS

We identified eight pediatric cases with ALEP. The causative agent was an herbal product in six cases, and pustular eruption was located on the face. In two cases, responsible agents were drugs (lamotrigine and amoxicillin-clavulanic acid). The eruptions were localized on the penis and extremities, respectively.

CONCLUSION

ALEP is very rare in the pediatric age group, and topical/systemic drugs or herbal products may be involved in the etiology.

Clinical characteristics and management of acute generalized exanthematous pustulosis with haemodynamic instability

Background

Acute generalized exanthematous pustulosis (AGEP) is a severe pustular drug eruption with rare reports of haemodynamic instability.

Objective

To describe the clinical characteristics, management, and outcomes of patients with AGEP‐associated haemodynamic instability.

Methods

This retrospective case series identified adult patients diagnosed with AGEP who had haemodynamic instability from November 2012 to February 2020 that were seen at two academic teaching hospitals with roles as a burn centre and tertiary referral centre at the University of Texas Southwestern Medical Center in Dallas, TX USA. Patients with a discharge diagnosis of AGEP that had haemodynamic instability during their eruption were included. Patients with a history of psoriasis, presentations thought to be a flare of generalized pustular psoriasis, or concurrent infection during eruption were excluded. AGEP with haemodynamic instability was characterized by degree of hypotension, dermatologic phenotype at time of dermatologic consultation, and management approach.

Results

This study included 19 patients with AGEP‐associated haemodynamic instability (mean age, 52 years; age range, 29–76 years; 11 (58%) female). Patients were classified on a spectrum of haemodynamic instability; three had sustained hypotension, 10 had hypotension with organ dysfunction, and six had shock. Patients with AGEP‐associated haemodynamic instability had a range of dermatologic phenotypes at initial consultation: subtle exanthematous eruption with minimal pustules, typical eruption with pustules and flexural predominance, and severe eruption with features of Stevens–Johnson syndrome. Both topical and systemic corticosteroids were used for treatment of several patients. Of the patients that required vasopressors and received systemic steroids, the majority were off vasopressors within 24 h of steroid initiation.

Conclusion

Approximately 22% of patients presenting with AGEP to a tertiary referral center had haemodynamic instability. Clinicians should be aware that dermatologic phenotype of AGEP at presentation does not correlate with development of haemodynamic instability.

Generalized pustular psoriasis (von Zumbusch)

Generalized pustular psoriasis (von Zumbusch) is a rare and acute eruption characterized by multiple sterile pustules over an erythematous and edematous background, eventually associated with psoriasis vulgaris. Classically, it manifests as a potentially severe systemic picture and demands prompt diagnosis and intervention. The duration of each flare-up and intervals between the pustular episodes is extremely variable. Recently, genetic abnormalities have been identified mainly in the familial and early variants of this disease. The therapeutic arsenal is limited; however, new drugs being evaluated aim to control both pustular flare-ups and disease recurrences.

Methods for Identifying Culprit Drugs in Cutaneous Drug Eruptions: A Scoping Review

BACKGROUND

Cutaneous drug eruptions are a significant source of morbidity, mortality, and cost to the healthcare system. Identifying the culprit drug is essential; however, despite numerous methods being published, there are no consensus guidelines.

OBJECTIVES

Conduct a scoping review to identify all published methods of culprit drug identification for cutaneous drug eruptions, compare the methods, and generate hypotheses for future causality assessment studies.

ELIGIBILITY CRITERIA

Peer-reviewed publications involving culprit drug identification methods.

SOURCES OF EVIDENCE

Medline, Embase, and Cochrane Central Register of Controlled Trials.

CHARTING METHODS

Registered PRISMA-ScR format protocol on Open Science Forum.

RESULTS

In total, 109 studies and 26 reviews were included comprising 656,635 adverse drug events, most of which were cutaneous. There were 54 methods of culprit drug identification published, categorized as algorithms, probabilistic approaches, and expert judgment. Algorithms had higher sensitivity and positive predictive value, but lower specificity and negative predictive value. Probabilistic approaches had lower sensitivity and positive predictive value, but higher specificity and negative predictive value. Expert judgment was subjective, less reproducible, but the most frequently used to validate other methods. Studies suggest that greater accuracy may be achieved by specifically assessing cutaneous drug eruptions and using combinations of causality assessment categories.

CONCLUSIONS

Culprit drug identification for adverse drug reactions remains a challenge. Many methods have been published, but there are no consensus guidelines. Using causality assessment methods specifically for cutaneous drug eruptions and combining aspects of the different causality assessment categories may improve efficacy. Further studies are needed to validate this hypothesis.

Drug Hypersensitivity Reactions

Drug hypersensitivity reactions are a diverse group of reactions mediated by the immune system after exposure to a drug. The Gell and Coombs classification divides immunologic DHRs into 4 major pathophysiologic categories based on immunologic mechanism. Anaphylaxis is a Type I hypersensitivity reaction that requires immediate recognition and treatment. Severe cutaneous adverse reactions (SCARs) are a group of dermatologic diseases that result from a Type IV hypersensitivity process and include drug reaction with eosinophilia and systemic symptom (DRESS) syndrome, Stevens-Johnson Syndrome (SJS), toxic epidermal necrolysis (TEN), and acute generalized exanthematous pustulosis (AGEP). Other types of reactions are slow to develop and do not always require rapid treatment. Emergency physicians should have a good understanding of these various types of drug hypersensitivity reactions and how to approach the patient regarding evaluation and treatment.