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Yamashita A, Fukui T, Akasaka E, Nakajima K, Nakano H, Sawamura D, Hamaya T. Acquired cutis laxa secondary to acute generalized exanthematous pustulosis: A case report and mini-review of literature. J Dermatol 2024; 51:287-293. [PMID: 37334758 DOI: 10.1111/1346-8138.16860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 05/24/2023] [Accepted: 05/29/2023] [Indexed: 06/20/2023]
Abstract
Cutis laxa presents as loose redundant skin folds and loss of dermal elastic tissue. Acquired cutis laxa (ACL) is characterized by later onset. It has been reported in association with various kinds of neutrophilic dermatoses, drugs, metabolic disorders, and autoimmune disorders. Acute generalized exanthematous pustulosis (AGEP) is usually classified as a severe cutaneous adverse reaction characterized by T cell-mediated neutrophilic inflammation. We previously reported a mild case of AGEP caused by gemcitabine in a 76-year-old man. Here, we report a case of ACL secondary to AGEP in this patient. He developed AGEP 8 days after gemcitabine administration. Four weeks after beginning chemotherapy, his skin had become atrophic, loose, and darkly pigmented in areas previously affected by AGEP. Histopathological examination revealed edema and perivascular lymphocytic infiltration but no neutrophilic infiltration in the upper dermis. Elastica van Gieson staining showed that the elastic fibers in all layers of the dermis were sparse and shortened. Electron microscopy showed elevated numbers of fibroblasts and altered elastic fibers with irregular surfaces. Finally, he was diagnosed with ACL secondary to AGEP. He was treated with topical corticosteroids and oral antihistamines. Skin atrophy decreased over 3 months. We summarize 36 cases (including our case) with ACL secondary to neutrophilic dermatosis. We discuss these clinical manifestations, causative neutrophilic disorders, treatments, and outcomes. The mean age of patients was 3.5 years. Five patients had an aortic lesion as systemic involvement. The most common causative neutrophilic disorders were Sweet syndrome (24 cases), followed by urticaria-like neutrophilic dermatosis (11 cases). There were no cases of AGEP except for our case. Although treatment for ACL secondary to neutrophilic dermatosis, such as dapsone, oral prednisolone, adalimumab, and plastic surgery were reported, ACL is generally refractory and irreversible. Our patient was considered reversibly cured due to the absence of continuous neutrophil-mediated elastolysis.
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Affiliation(s)
- Aya Yamashita
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tomohisa Fukui
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Eijiro Akasaka
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Koji Nakajima
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hajime Nakano
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Daisuke Sawamura
- Department of Dermatology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Tomoko Hamaya
- Department of Urology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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Zhang X, Zhuang K, Lyu X. Acute generalized exanthematous pustulosis complicated by cutaneous small vessel vasculitis: A case report and literature review. Australas J Dermatol 2023; 64:e262-e265. [PMID: 37154198 DOI: 10.1111/ajd.14065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/22/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare skin eruption characterized by widespread erythematous lesions covered with numerous pustules. Leukocytoclastic vasculitis is now considered an uncommon but possible histopathological feature within the clinical and pathological spectrum of AGEP. Our report describes a rare case of AGEP overlapping with cutaneous small vessel vasculitis, a condition that has only been reported once in the literature.
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Affiliation(s)
- Xingwei Zhang
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Kaiwen Zhuang
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyan Lyu
- Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China
- Laboratory of Dermatology, Clinical Institute of Inflammation and Immunology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, China
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Blaess M, Kaiser L, Sommerfeld O, Csuk R, Deigner HP. Drug triggered pruritus, rash, papules, and blisters - is AGEP a clash of an altered sphingolipid-metabolism and lysosomotropism of drugs accumulating in the skin? Lipids Health Dis 2021; 20:156. [PMID: 34743684 PMCID: PMC8573906 DOI: 10.1186/s12944-021-01552-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Accepted: 09/09/2021] [Indexed: 11/26/2022] Open
Abstract
Rash, photosensitivity, erythema multiforme, and the acute generalized exanthematous pustulosis (AGEP) are relatively uncommon adverse reactions of drugs. To date, the etiology is not well understood and individual susceptibility still remains unknown. Amiodarone, chlorpromazine, amitriptyline, and trimipramine are classified lysosomotropic as well as photosensitizing, however, they fail to trigger rash and pruritic papules in all individuals. Lysosomotropism is a common charcteristic of various drugs, but independent of individuals. There is evidence that the individual ability to respond to external oxidative stress is crosslinked with the elongation of long-chain fatty acids to very long-chain fatty acids by ELOVLs. ELOVL6 and ELOVL7 are sensitive to ROS induced depletion of cellular NADPH and insufficient regeneration via the pentose phosphate pathway and mitochondrial fatty acid oxidation. Deficiency of NADPH in presence of lysosomotropic drugs promotes the synthesis of C16-ceramide in lysosomes and may contribute to emerging pruritic papules of AGEP. However, independently from a lysosomomotropic drug, severe depletion of ATP and NAD(P)H, e.g., by UV radiation or a potent photosensitizer can trigger likewise the collapse of the lysosomal transmembrane proton gradient resulting in lysosomal C16-ceramide synthesis and pruritic papules. This kind of papules are equally present in polymorphous light eruption (PMLE/PLE) and acne aestivalis (Mallorca acne). The suggested model of a compartmentalized ceramide metabolism provides a more sophisticated explanation of cutaneous drug adverse effects and the individual sensitivity to UV radiation. Parameters such as pKa and ClogP of the triggering drug, cutaneous fatty acid profile, and ceramide profile enables new concepts in risk assessment and scoring of AGEP as well as prophylaxis outcome.
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Affiliation(s)
- Markus Blaess
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Jakob-Kienzle-Str. 17, D-78054, Villingen-Schwenningen, Germany
| | - Lars Kaiser
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Jakob-Kienzle-Str. 17, D-78054, Villingen-Schwenningen, Germany
- Institute of Pharmaceutical Sciences, University of Freiburg, Albertstraße 25, D-79104, Freiburg, Germany
| | - Oliver Sommerfeld
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Am Klinikum 1, D-07747, Jena, Germany
| | - René Csuk
- Organic Chemistry, Martin-Luther-University Halle-Wittenberg, Kurt-Mothes-Straße 2, D-06120, Halle (Saale), Germany
| | - Hans-Peter Deigner
- Institute of Precision Medicine, Medical and Life Sciences Faculty, Furtwangen University, Jakob-Kienzle-Str. 17, D-78054, Villingen-Schwenningen, Germany.
- EXIM Department, Fraunhofer Institute IZI, Schillingallee 68, D-18057, Leipzig, Rostock, Germany.
- Faculty of Science, Associated member of Tuebingen University, Auf der Morgenstelle 8, D- 72076, Tübingen, Germany.
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Owen CE, Jones JM. Recognition and Management of Severe Cutaneous Adverse Drug Reactions (Including Drug Reaction with Eosinophilia and Systemic Symptoms, Stevens-Johnson Syndrome, and Toxic Epidermal Necrolysis). Med Clin North Am 2021; 105:577-597. [PMID: 34059239 DOI: 10.1016/j.mcna.2021.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Severe cutaneous adverse reactions to medications (SCARs) include drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, toxic epidermal necrolysis, and acute generalized exanthematous pustulosis. They are all non-immunoglobulin E mediated hypersensitivity reaction patterns, distinguished from simple cutaneous drug eruptions by immunologic pathogenesis and internal organ involvement. Herein the clinical features, diagnostic workup, and management considerations are presented for each of these major SCARs.
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Affiliation(s)
- Cindy England Owen
- Division of Dermatology, Department of Medicine, 3810 Springhurst Boulevard, Suite 200, Louisville, KY 40241, USA.
| | - Jordan M Jones
- Division of Dermatology, Department of Medicine, 3810 Springhurst Boulevard, Suite 200, Louisville, KY 40241, USA
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Price KN, Hendricks AJ, Goodrich ME, Krase JM, Shi VY. Widespread pustular eruption following probiotic use. Dermatol Online J 2020; 26:13030/qt7gz2d8t0. [PMID: 33342179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 07/05/2020] [Accepted: 07/28/2020] [Indexed: 06/12/2023] Open
Abstract
A 26-year-old woman with Crohn disease and palmoplantar psoriasis on ustekinumab presented with a diffuse and intensely pruritic rash with a few pin-point pustules within days after initiation of an over-the-counter Align brand probiotic. Biopsy revealed psoriasiform and spongiotic dermatitis with spongiform subcorneal pustules and scattered eosinophils, consistent with acute generalized exanthematous pustulosis. Our case highlights a unique presentation of acute generalized exanthematous pustulosis following probiotic exposure with fewer than usual pustular lesions. IL23 suppression by ustekinumab may have contributed to the patient's reduced pustular presentation.
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Affiliation(s)
| | | | | | | | - Vivian Y Shi
- Division of Dermatology, University of Arkansas for Medical Sciences, Little Rock, AR.
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Isom J, Braswell DS, Siroy A, Auerbach J, Motaparthi K. Clinical and histopathologic features differentiating acute generalized exanthematous pustulosis and pustular psoriasis: A retrospective series. J Am Acad Dermatol 2020; 83:265-267. [PMID: 32173359 DOI: 10.1016/j.jaad.2020.03.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Revised: 01/28/2020] [Accepted: 03/04/2020] [Indexed: 01/01/2023]
Affiliation(s)
- James Isom
- Department of Pathology, University of Florida Medicine, Gainesville, Florida
| | - Diana S Braswell
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida
| | - Alan Siroy
- Department of Pathology, University of Florida Medicine, Gainesville, Florida
| | - Jena Auerbach
- Department of Pathology, University of Florida Medicine, Gainesville, Florida
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida.
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Abstract
Cutaneous adverse drug reactions are unpredictable and include various different skin conditions of varying degrees of severity. The most concerning are usually referred to as severe cutaneous adverse reactions (SCARs) and include acute generalized exanthematous pustulosis (AGEP), drug reaction with eosinophilia and systemic symptoms (DRESS), also known as drug-induced hypersensitivity syndrome (DiHS) or hypersensitivity syndrome (HSS), Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN). All are delayed type IV hypersensitivity reactions in which a T-cell-mediated drug-specific immune response is responsible for causing the disease. Nonetheless, specific T-cell subpopulations develop in response to certain environmental conditions and produce cytokines that orchestrate the various phenotypes. Cytotoxic T lymphocytes (CTLs), T-helper type 1 (Th1), Th2, Th17, and regulatory T cells (Treg), among other T-cell subpopulations, participate in the development of SCAR phenotypes. Cell subpopulations belonging to the innate immune system, comprising natural killer cells, innate lymphoid cells, monocytes, macrophages and dendritic cells, can also participate in shaping specific immune responses in various clinical conditions. Additionally, tissue-resident cells, including keratinocytes, can contribute to epidermal damage by secreting chemokines that attract pro-inflammatory immunocytes. The final phenotypes in each clinical entity result from the complex interactions between a variety of cell lineages, their products, soluble mediators and genetic and environmental factors. Although the pathophysiology of these reactions is not fully understood, intensive research in recent years has led to major progress in our understanding of the contribution of certain cell types and soluble mediators to the variability of SCAR phenotypes.
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Affiliation(s)
- Teresa Bellón
- La Paz Hospital Health Research Institute-IdiPAZ, Pº Castellana 261, 28046, Madrid, Spain.
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Choon SE, Der YS, Lai NLJ, Yu SEE, Yap XL, Nalini NM. Clinical characteristics, culprit drugs and outcome of patients with Acute Generalised Exanthematous Pustulosis seen in Hospital Sultanah Aminah, Johor Bahru. Med J Malaysia 2018; 73:220-225. [PMID: 30121684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Acute generalised exanthematous pustulosis (AGEP) is a rare, cutaneous reaction characterised by sudden onset of numerous, non-follicular, sterile pustules on oedematous erythematous skin, accompanied by fever and neutrophilia. AGEP is predominantly drug-induced. Skin lesions appear rapidly within 1-3 days of drug exposure and upon drug withdrawal, resolve rapidly within 15 days. OBJECTIVE To determine the clinical characteristics, culprit drugs and outcome of patients with AGEP. METHODS A retrospective note review of all AGEP patients seen from 2001-2015. RESULTS Among 21 AGEP patients, 76% were Malays, 9.5% Chinese, 9.5% Indians, and 5% Iban. Sixteen were females and 5 were males. Median age of patients was 40 years (IQR: 26). The main culprit drug was amoxicillin (10 cases), followed by cloxacillin (three cases), phenytoin (two cases) and one case each of carbamazepine, sulphasalazine, allopurinol, cephalexin, ceftriaxone, celecoxib and herbal product. The median time from drug initiation to onset of AGEP was 3 days (IQR: 5.5). Fever was documented in 52.4 %, mucosal involvement 9.5%, purpura 4.7% and blisters 4.7%. Neutrophilia was observed in 63.6% of patients and eosinophilia in 28.5%. While most patients required admission (67%), all achieved complete recovery within 15 days without any sequela. CONCLUSIONS AGEP predominantly affects Malay females in this study. The most common culprit drug was amoxicillin. Our patients exhibited the classic clinical manifestations of AGEP and confirmed the generally benign nature of this reaction upon drug withdrawal. Although the overall prognosis is good, prompt diagnosis of AGEP is important because drug withdrawal is the mainstay therapy.
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Affiliation(s)
- S E Choon
- Monash University, Jeffrey Cheah School of Medicine and Health Sciences, Malaysia.
| | - Y S Der
- Monash University, Jeffrey Cheah School of Medicine and Health Sciences, Malaysia
| | - N L J Lai
- Monash University, Jeffrey Cheah School of Medicine and Health Sciences, Malaysia
| | - S E E Yu
- Monash University, Jeffrey Cheah School of Medicine and Health Sciences, Malaysia
| | - X L Yap
- Monash University, Jeffrey Cheah School of Medicine and Health Sciences, Malaysia
| | - N M Nalini
- Hospital Sultanah Aminah, Department of Dermatology, Johor Bahru, Malaysia
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Abstract
This case report demonstrates the challenges of diagnosing and managing acute generalized exanthematous pustulosis (AGEP) presenting as septic shock. The disseminated, erythematous, pustular rash is a common feature. However, extensive organ involvement and life-threatening hypotension are unusual. The constellation of signs has not previously been documented following amoxicillin therapy. Toxic epidermal necrolysis (TEN) and toxic shock syndrome (TSS) were considered in addition to AGEP because of the systemic presentation. AGEP was diagnosed following histopathology (TEN was ruled out based on limited necrotic keratinocytes and lack of epidermal necrosis) and a negative antistreptolysin O titer (eliminated TSS). Antibiotic therapy for septic shock was provided before the diagnosis was confirmed as AGEP. Upon confirmation of the AGEP diagnosis, antibiotics were discontinued and a 5-day course of oral prednisone (40 mg/d) was initiated in addition to topical half-strength (0.05%) betamethasone valerate. The patient rapidly improved and was discharged. Outpatient patch testing confirmed amoxicillin as the culprit drug. In conclusion, it is critical to realize that AGEP cannot be ruled out with a septic shock presentation. Recent drug history is critical in recognizing an adverse drug reaction, and patch testing is useful for determining the culpable drug when the diagnosis is AGEP.
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Affiliation(s)
- Christina Yek
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Arjun Gupta
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
| | - Melissa Mauskar
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas
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Rocci E, Park K, Hutchens K, Winterfield L. First report of mesalamine (5-aminosalicylic acid) as the causative agent in a case of acute generalized exanthamous pustulosis. Dermatol Online J 2017; 23:13030/qt7046n97m. [PMID: 28329471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 01/20/2017] [Indexed: 06/06/2023] Open
Abstract
Acute generalized exanthamous pustulosis (AGEP)is a rare eruption of non-follicular sterile pustuleson a diffuse background of erythema and edema,commonly associated with fever and leukocytosis.Antibiotics are implicated in most cases; however,other drugs have been reported to cause AGEP. Wereport a case of a 73-year-old man with a historyof ulcerative colitis who presented with a diffusepustular rash, renal failure, elevated liver functiontests, and leukocytosis with neutrophilia. A week priorto admission, the patient was started on mesalamineto treat colitis. Upon admission, a workup includinga skin biopsy was performed and was consistentwith AGEP. Mesalamine was discontinued, and thepatient's skin eruption, renal function, liver functiontests, and leukocytosis subsequently improved.Mesalamine has an unknown mechanism of action.However, it is thought to be an anti-inflammatoryagent that blocks the production of leukotrienesand prostaglandins and is an immunosuppressantthat increases the release of adenosine, whichinterferes with leukocyte function. The decrease inprostaglandin synthesis or deregulation of leukocytefunction caused by mesalamine may be the etiologyin this case. Discontinuation of the offending agentleads to resolution of AGEP, as it did in this patient.
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Affiliation(s)
| | - Kelly Park
- Skin Institute of South Florida, Coral Springs, Florida. kyunghwamd@ gmail.com
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di Meo N, Stinco G, Patrone P, Trevisini S, Trevisan G. Acute localized exanthematous pustulosis caused by flurbiprofen. Cutis 2016; 98:E9-E11. [PMID: 28040819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Affiliation(s)
- Nicola di Meo
- Institute of Dermatology and Venereology, University of Trieste, Italy
| | - Giuseppe Stinco
- Department of Clinical and Experimental Pathology and Medicine, Institute of Dermatology, University of Udine, Italy
| | - Pasquale Patrone
- Department of Clinical and Experimental Pathology and Medicine, Institute of Dermatology, University of Udine, Italy
| | - Sara Trevisini
- Institute of Dermatology and Venereology, University of Trieste, Italy
| | - Giusto Trevisan
- Institute of Dermatology and Venereology, University of Trieste, Italy
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Shrestha A, Rizzo V. Acute Generalized Exanthematous Pustulosis Secondary to Nifedipine. S D Med 2016; 69:199-201. [PMID: 28863416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Anup Shrestha
- Avera Mckennan Hospital and University Medical Center, Sioux Falls, South Dakota
| | - Vincent Rizzo
- Icahn School of Medicine at Mount Sinai, Queens Hospital Center, Jamaica, New York
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Navarrete-Dechent C, Curi-Tuma M, Moll-Manzur C, Dossi MT, Manríquez JJ, González S, Fich F. [Acute generalized exanthematous pustulosis associated with Mycoplasma pneumoniae infection: a case report]. Rev Chilena Infectol 2016; 33:66-70. [PMID: 26965881 DOI: 10.4067/s0716-10182016000100011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 10/27/2015] [Indexed: 11/17/2022] Open
Abstract
Acute generalized exanthematous pustulosis is an uncommon skin eruption, characterized by fever and the rapid onset of disseminated, non-follicular, sterile pustules, over an erythematous skin background. It is usually classified as a severe cutaneous adverse drug reaction, whose most relevant triggers are antibiotics and anticonvulsants. However, viral and bacterial infections have also rarely been associated with this dermatosis. We report the case of a patient, who developed lesions of acute generalized exanthematous pustulosis as an extrapulmonary manifestation of Mycoplasma pneumoniae infection.
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Pearson KC, Morrell DS, Runge SR, Jolly P. Prolonged pustular eruption from hydroxychloroquine: an unusual case of acute generalized exanthematous pustulosis. Cutis 2016; 97:212-216. [PMID: 27023083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous eruption that often is a reaction to medications, most commonly antibiotics. Clinically, AGEP closely mimics pustular psoriasis and also is similar to subcorneal pustular dermatosis and IgA pemphigus. For clinicians, it is important to differentiate AGEP from pustular psoriasis. Acute generalized exanthematous pustulosis will have an acute drug association. Few cases have been known to be caused by hydroxychloroquine (HCQ). Proper therapeutic management of AGEP includes withdrawal of the offending agent, and resolution typically occurs within 15 days. We report a case of AGEP after HCQ administration that did not follow the usual course of resolution after medication cessation. The patient continued to experience cutaneous eruptions that waxed and waned for 81 days. Hydroxychloroquine has a particularly long half-life and is a known cause of AGEP; therefore, it is possible that HCQ-induced AGEP may not follow the typical rapid recovery time.
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Cranga TA, Simpson MA, Featherstone P. Acute generalised exanthematous pustulosis (AGEP)-a potential pitfall for the acute physician. Acute Med 2016; 15:140-144. [PMID: 27759749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Acute generalised exanthematous pustulosis is a rare drug-induced dermatosis with an incidence of 1-5 cases per million cases per year, characterised by the appearance of hundreds of sterile pustules over erythematous and oedematous skin. Fever and neutrophilia are usually present. It has a rapid course and usually resolves following discontinuation of the precipitating drug or as a result of topical corticosteroid treatment. A patient with AGEP, who presented with generalized pustulosis lesions after the use of Flucloxacillin for cellulitis is described, along with the management and differential diagnosis of this condition.
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Affiliation(s)
- Kumiko Taguchi
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Masahiro Oka
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshinori Bito
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Chikako Nishigori
- Division of Dermatology, Department of Internal Related, Kobe University Graduate School of Medicine, Kobe, Japan
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Grelck K, Stewart N, Rosen L, Sukal S. Acute generalized exanthematous pustulosis associated with ranolazine. Cutis 2015; 96:E18-E21. [PMID: 26682297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a potentially widespread, pustular, cutaneous eruption commonly associated with drug administration. We report a case of AGEP associated with the antianginal, anti-ischemic agent ranolazine. The patient, an 83-year-old man, had a validation score of 10 out of 12 in accordance with the EuroSCAR criteria (8-12 is considered definitive), although it may have been higher had blood work been performed prior to diagnosis and treatment. After ranolazine was discontinued and a course of tapered oral prednisone was prescribed, the rash resolved with subsequent desquamation.
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Affiliation(s)
- Kurt Grelck
- Forefront Dermatology, Stevens Points, Wisconsin, USA
| | | | - Les Rosen
- Dermpath Diagnostics, Pompano Beach, Florida, USA
| | - Sean Sukal
- Sukal Skin Institute, Boca Raton, Florida, USA
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Affiliation(s)
- Zhenying Zhang
- Hong Kong University-Affiliated Shenzhen Hospital, Shenzhen, China
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Pastushenko I, Gracia-Cazaña T, Morales-Moya AL, Grasa MP. [Acute cutaneous pustular eruption due to hydroxychloroquine]. Med Clin (Barc) 2014; 143:e13. [PMID: 24908623 DOI: 10.1016/j.medcli.2014.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/22/2014] [Indexed: 11/19/2022]
Affiliation(s)
- Ievgenia Pastushenko
- Departamento de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - Tamara Gracia-Cazaña
- Departamento de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España.
| | - Ana Luisa Morales-Moya
- Departamento de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - M Pilar Grasa
- Departamento de Dermatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
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Vassallo C, Derlino F, Brazzelli V, D'Ospina RD, Borroni G. Acute generalized exanthematous pustulosis: report of five cases and systematic review of clinical and histopathological findings. GIORN ITAL DERMAT V 2014; 149:281-90. [PMID: 24819755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare, drug-related pustular eruption usually starting from folds with edema and erythema and with subsequent spreading. Clinically AGEP is characterized by the sudden appearance of dozen of sterile, non follicular, small pustules on erythematous and edematous skin. Mild non erosive mucosal involvement, mostly oral, may sometimes occur. Fever, neutrophilia and peripheral blood eosinophilia (in a third of patients) are present. Other skin signs such as facial edema, purpura, target-like lesions and blisters have been described but are not typical for AGEP. Diagnostic criteria for AGEP were established by an international committee of experts, the European Study of Severe Cutaneous Adverse Reactions (EuroSCAR). The most relevant histopathological feature is represented by the detection of non-follicular subcorneal and/or intracorneal spongiform pustules that are usually large, contiguous and tend to coalesce. After elimination of the causative drug, pustules usually spontaneously disappear in a few days with desquamation and the reaction fully resolves within 15 days. Internal organs are not usually involved and no systemic treatment is required. Withdrawal of the culprit drug is mandatory. Although AGEP is a self-limiting disease with a favourable prognosis, secondary infections are a not infrequent complication in patients in poor general medical conditions. The reported mortality is about 5%. The most severe cases are associated with drug rechallenge.
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Affiliation(s)
- C Vassallo
- Dermatology Unit, Department of Clinical‑Surgical Diagnostic and Pediatric Sciences, University of Pavia Policlinico San Matteo IRCCS Foundation, Pavia, Italy -
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Gordon Spratt EA, Schmidt AN, Kantrow SM. Daptomycin-induced acute generalized exanthematous pustulosis. Cutis 2014; 93:E10-E12. [PMID: 24999649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- Elizabeth A Gordon Spratt
- The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 38th St, Floor 11, New York, NY 10016, USA.
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Badawi AH, Tefft K, Fraga GR, Liu DY. Cetirizine-induced acute generalized exanthematous pustulosis: a serious reaction to a commonly used drug. Dermatol Online J 2014; 20:22613. [PMID: 24852773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 05/15/2014] [Indexed: 06/03/2023] Open
Abstract
Acute generalized exanthematous pustulosis (AGEP) is an abrupt cutaneous adverse reaction usually in response to medications. It is generally a self-limiting disease if diagnosed promptly and the offending agent discontinued. Cetirizine, a commonly used anti-histamine medication for the treatment of allergic diseases has few reported side effects and is normally well-tolerated and effective. Herein, the first reported case of cetirizine induced AGEP is presented, followed by a discussion of the clinical and pathological aspects of this adverse cutaneous reaction to a widely used drug. Awareness of this reaction is vital owing to the extensive use of cetirizine and the importance of drug cessation once the reaction is identified. Lastly, other pustular cutaneous reactions may present similarly and therefore accurate identification of this disease can prevent unnecessary diagnostic testing.
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Huilaja L, Kallioinen M, Soronen M, Riekki R, Tasanen K. Acute localized exanthematous pustulosis on inguinal area secondary to piperacillin/tazobactam. Acta Derm Venereol 2014; 94:106-7. [PMID: 23817479 DOI: 10.2340/00015555-1629] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Laura Huilaja
- Deparment of Dermatology, University of Oulu, Aapistie 5A, FIN-90220 Oulu, Finland.
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26
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Otero Rivas MM, Sánchez Sambucety P, García-Ruiz de Morales JM, Pérez Paredes G, Rodríguez Prieto MA. Acute generalized exanthematous pustulosis due to dextromethorphan. Dermatol Online J 2013; 19:20030. [PMID: 24139370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Accepted: 10/16/2013] [Indexed: 06/02/2023] Open
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare, severe, pustular, cutaneous reaction. We report a case in which a patient developed AGEP after the intake of 3 different antitussive agents containing dextromethorphan as the only ingredient in common.
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Kiyohara T, Sawai T, Ido H, Kumakiri M. Toxic epidermal necrolysis with some features of acute generalized exanthematous pustulosis. Acta Derm Venereol 2013; 93:212-4. [PMID: 22930254 DOI: 10.2340/00015555-1438] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Deng A, Lowitt M. Acute generalized erythematous pustulosis occurring with Hailey-Hailey disease. Skinmed 2012; 10:251-253. [PMID: 23008946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
A 70-year-old woman urgently presented with severe eruptive skin dermatitis associated with fever and malaise 7 days after taking clindamycin for an unknown skin eruption. She had a 40-year-long history of well-controlled Hailey-Hailey disease. Physical examination revealed erythrodermic skin changes covering more than 80% of the patient's body surface, with hundreds of nonfollicular pustules. Many of the pustules fused into large bullae, involving the intertriginous as well as the extensor areas, sparing the mucosa. Her body temperature was 103 degrees F. Laboratory workup was significant for neutrophilia with a white cell count > 10,000/mm3.
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Affiliation(s)
- April Deng
- Department of Pathology, University of Massachusetts School of Medicine, Worcester, MA 01605, USA.
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Holscher CM, Mauck SK, Armstrong L, Buchanan JA. Man with rash and nausea. Acute generalized exanthematous pustulosis after cephalexin use. Ann Emerg Med 2012; 58:508, 516. [PMID: 22098993 DOI: 10.1016/j.annemergmed.2011.03.059] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2011] [Revised: 01/05/2011] [Accepted: 03/31/2011] [Indexed: 11/17/2022]
Affiliation(s)
- Courtenay M Holscher
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, USA
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Matsushita H, Ishiguro T, Kurabayashi T, Shibuya M. Acute generalized exanthematous pustulosis during the puerperal period: a case report. CLIN EXP OBSTET GYN 2012; 39:414-416. [PMID: 23157063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
BACKGROUND Acute generalized exanthematous pustulosis (AGEP) is an uncommon adverse cutaneous reaction, most commonly associated with drugs. CASE A 38-year-old primigravida whose labor had been induced developed erythema over her chest and abdomen. She was transferred to our department after a failed vacuum extraction, and delivered a mature infant by forceps. On day three postpartum she developed a 40.4 degrees C fever. Although ceftriaxone was administered, her fever persisted (>38 degreesC). On day six of the puerperium, diffuse non-follicular pustules appeared over her neck and trunk, and AGEP was suspected. Two days after ceftriaxone was withdrawn, the eruptions started to resolve without any medical intervention. CONCLUSION Once the diagnosis of AGEP has been made, the antibiotics being administered must be discontinued. If continued treatment is required, pharmacologically distinct antibiotics must be used instead to aid the rapid self-limitation of the disease.
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Affiliation(s)
- H Matsushita
- Department of Obstetrics & Gynecology, Niigata City General Hospital, Shumoku, Chuo-ku, Niigata, Japan.
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31
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Sener O, Kose Ö, Kartal Ö, Safali M. Acute generalized exanthematous pustulosis due to oral use of blue dyes. Korean J Intern Med 2011; 26:360-3. [PMID: 22016599 PMCID: PMC3192211 DOI: 10.3904/kjim.2011.26.3.360] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2009] [Revised: 11/02/2009] [Accepted: 11/18/2009] [Indexed: 11/27/2022] Open
Abstract
Acute generalized exanthematous pustulosis is a rare severe pustular cutaneous adverse reaction characterized by a rapid clinical course with typical histological findings. It is accompanied by fever and acute eruption of non-follicular pustules overlying erythrodermic skin. The causative agents are most frequently antibacterial drugs. We present a patient with acute generalized exanthematous pustulosis caused by methylene blue and indigotin dyes.
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Affiliation(s)
- Osman Sener
- Division of Allergy, Department of Internal Medicine, Gülhane Military Medical Academy and Medical School, Ankara, Turkey
| | - Ösman Kose
- Department of Dermatology, Gülhane Military Medical Academy and Medical School, Ankara, Turkey
| | - Özgür Kartal
- Division of Allergy, Department of Internal Medicine, Gülhane Military Medical Academy and Medical School, Ankara, Turkey
| | - Mukerrem Safali
- Department of Pathology, Gülhane Military Medical Academy and Medical School, Ankara, Turkey
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Córdoba S, García-Donoso C, Villanueva CA, Borbujo J, Moreno A. Allergic contact dermatitis from methylchloroisothiazolinone, with acute exanthematous pustulosis-like histopathologic changes. Dermatitis 2011; 22:60-61. [PMID: 21291647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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Mebazaa A, Kort R, Zaiem A, Elleuch D, Moula H, Cheikhrouhou R, Trojjet S, Mokni M, Ben Osman A, Daghfous R. [Acute generalized exanthematous pustulosis. Study of 22 cases]. Tunis Med 2010; 88:910-915. [PMID: 21136359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
BACKGROUND Acute generalized exanthematous pustulosis (AGEP) is an uncommon but severe dermatosis, characterized by acute occurrence of fever, and erythemato-oedematous rash, covered by sterile nonfollicular pustules. Most cases of AGEP have been described in association with the intake of drugs. AIM To determine clinical and prognostic features of AGEP in our patients. METHODS All cases of AGEP diagnosed between 1992 and 2007 according to EuroSCAR criteria have been collected. RESULTS Twenty two patients (16 female, 6 male) with a mean age of 40.9 years (19-81) were included in the study. Clinical features showed in all cases an acute eruption with oedematous erythema, rapidly covered by nonfollicular pustules. The rash was mainly localized on big folds, trunk and/or limbs in 14 cases and generalized in 8 cases. A biological cytolysis was noted in 5 cases and a functional acute renal failure was objected in 2 cases. Etiological work up has found an association with the intake of drugs in 14 cases, a toxic cause (mercury) in 1 case and a B19 parvovirus infection in one case. The mean delay between drug intake and beginning of the eruption was 5 days (24 hours- 15 days). Pharmacovigilance enquiry has concluded to a probable or plausible causality in all our cases. Clinical features improved with drug or toxic withdrawal with a mean delay of 7 days (4 -12 days). A relapse of AGEP was observed in 2 cases after accidental introduction of the drug. CONCLUSION AGEP is a cutaneous side effect not to ignore, because of its severe prognosis in case of systemic involvement and the possibility of relapses in case of retake of the causal drug.
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Affiliation(s)
- Amel Mebazaa
- Service de Dermatologie, Hôpital LA RABTA, Tunis, Tunisia
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Suárez-Amor O, Cabanillas M, Monteagudo B, Ramírez-Santos A, Pérez-Valcárcel J, De Las Heras C. Acute generalized exanthematous pustulosis or toxic epidermal necrolysis? Pediatr Dermatol 2010; 27:559-60. [PMID: 21182651 DOI: 10.1111/j.1525-1470.2010.01203.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Kim SW, Lee UH, Jang SJ, Park HS, Kang YS. Acute localized exanthematous pustulosis induced by docetaxel. J Am Acad Dermatol 2010; 63:e44-6. [PMID: 20633784 DOI: 10.1016/j.jaad.2009.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 05/04/2009] [Accepted: 05/10/2009] [Indexed: 11/19/2022]
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38
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Comstedt LR, Gregersen JH, Bygum A. [Acute generalized exanthematous pustulosis]. Ugeskr Laeger 2010; 172:628-629. [PMID: 20184822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous drug reaction often caused by beta-lactam antibiotics. The reaction is characterized by sudden occurrence of a generalized exanthema, developing within 1-2 days. Hundreds of sterile pustules arise on an oedematous and erythematous base. The cutaneous symptoms are accompanied by fever and neutrophilia. The pustules resolve within 4-10 days once the causative drug has been withdrawn. We hereby present a classical case of amoxicillin-induced AGEP in a 34-year-old woman.
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Barcik K, Protas-Drozd F, Weiss-Rostkowska W, Flis E, Placek W. [Acute generalised exanthematosus pustulosis (AGEP) due to diltiazem--a case report]. Kardiol Pol 2009; 67:887-891. [PMID: 19784887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
A case of a patient who developed acute generalised exanthemotosus pustulosis (AGEP) due to diltiazem therapy is presented. On the day of the admission to hospital skin changes were present on the whole body in the form of sterile spots of an erythema origin. The laboratory tests showed anaemia, leucocytosis, hypocalcaemia, increased liver enzymes and increased ESR. The skin changes were accompanied by high temperature and bad condition. On the basis of medical history, clinical picture and medical tests, AGEP was diagnosed. After the application of a general treatment with erythromycin and external preparations, the skin changes subsided completely.
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Affiliation(s)
- Katarzyna Barcik
- Katedra i Klinika Dermatologii, Chorób Przenoszonych Droga Płciowa i Immunodermatologii, Uniwersytet Mikołaja Kopernika w Toruniu, Collegrium Medicum, ul.Kurpińskiego 5, 85-096 Bydgoszcz.
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