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Acute Generalized Exanthematous Pustulosis (AGEP) in 12 Patients Treated for SARS-CoV-2 Positive Pneumonia. Am J Dermatopathol 2021; 43:342-348. [PMID: 33405402 DOI: 10.1097/dad.0000000000001819] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
ABSTRACT The novel coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is rapidly spreading throughout the world. The study describes 12 patients with SARS-CoV-2 pneumonia, who developed an acute erythematous rash with nonfollicular pinhead-sized pustules, without mucosal involvement. The clinical differential diagnosis was viral rash, acute generalized exanthematous pustulosis (AGEP), or multiform erythema. computed tomography with a diagnosis of interstitial pneumonia and a respiratory tract sample positive for SARS-CoV-2 in a reverse transcriptase polymerase chain reaction assay. Patients had signs of respiratory distress and were treated with hydroxychloroquine, darunavir, ritonavir, heparin, ceftriaxone, and azithromycin. Punch biopsies showed subcorneal pustules typical of AGEP. Dermal microvascular injury and thrombosis as described in skin damage by SARS-CoV-2 infection was not observed. The direct immunofluorescence for IgG, IgA, IgM, and C3 was negative in 8 patients investigated. A polymerase chain reaction for RNA SARS-CoV-2 performed on frozen skin was negative in 5 of 6 patients. Most of our patients were treated with systemic corticosteroids. After some days (4-10), the diffuse erythema and pustules had improved. AGEP is classified as a severe cutaneous adverse reaction, provoked by drugs and acute infections. Characteristically, removal of the offending agent leads to spontaneous resolution typically in less than 15 days. The recognition of AGEP is important, in order to avoid confusion with a systemic infection and consequently to avoid incorrect treatment. Cutaneous adverse reactions to drugs are common and are major health problems worldwide causing considerable costs for health care systems. We suggest that in the patients with AGEP during SARS-CoV-2 pneumonia, viral infection is a risk factor for developing drug reaction.
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Bressler MY, Minkowitz J, Pathak N, Mekaiel A, Tamez R. Acute Generalized Exanthematous Pustulosis in an African American Male Caused by Trimethoprim-Sulfamethoxazole. Cureus 2020; 12:e9591. [PMID: 32923197 PMCID: PMC7478609 DOI: 10.7759/cureus.9591] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a rare drug-induced autoimmune disease that presents with hundreds of sterile pustules and systemic symptoms. Genetic predisposition, race, and medications prescribed are all factors in AGEP’s frequency, which occurs most commonly in Caucasians and with the use of macrolides and aminopenicillins. Cases of AGEP with sulfonamides or in African American patients are rare. To our knowledge, this is the first documented example of trimethoprim-sulfamethoxazole-induced AGEP in an African American male. In this article, we will further discuss our case and review the literature.
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Affiliation(s)
- Moshe Y Bressler
- Dermatology, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Jeremy Minkowitz
- Dermatology, New York Institute of Technology College of Osteopathic Medicine, Old Westbury, USA
| | - Naeha Pathak
- Dermatology, Jamaica Hospital Medical Center, Jamaica, USA
| | - Andrew Mekaiel
- Internal Medicine, Jamaica Hospital Medical Center, Jamaica, USA
| | - Rebecca Tamez
- Dermatology, Jamaica Hospital Medical Center, Jamaica, USA
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Consales V, Campanati A, Bobyr I, Molinelli E, Brisigotti V, Giuliodori K, Ganzetti G, Giangiacomi M, Offidani A. Relapsing acute generalized exanthematous pustolosis: a guess. GIORN ITAL DERMAT V 2019; 154:82-83. [PMID: 30616333 DOI: 10.23736/s0392-0488.16.05292-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Veronica Consales
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
| | - Anna Campanati
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy -
| | - Ivan Bobyr
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
| | - Elisa Molinelli
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
| | - Valerio Brisigotti
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
| | - Katia Giuliodori
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
| | - Giulia Ganzetti
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
| | - Mirella Giangiacomi
- Institute of Pathological Anatomy and Histopathology, Polytechnic University of Marche Region, Ancona, Italy
| | - Annamaria Offidani
- Unit of Dermatology, Department of Clinical and Molecular Sciences, Polytechnic University of Marche Region, Ancona, Italy
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Abstract
Acute generalised exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction and is attributed to drugs in more than 90% of cases. It is a rare disease, with an estimated incidence of 1–5 patients per million per year. The clinical manifestations characterised by the rapid development of sterile pustular lesions, fever and leucocytosis. Number of drugs has been reported to be associated with AGEP, most common being the antibiotics. Histopathologically there is intraepidermal pustules and papillary dermal oedema with neutrophilic and eosinophilic infiltrations. Systemic involvement can be present in more severe cases. Early diagnosis with withdrawal of the causative drug is the most important step in the management. Treatment includes supportive care, prevention of antibiotics and use of a potent topical steroid.
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Affiliation(s)
- Abhishek De
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Sudip Das
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Aarti Sarda
- Department of Dermatology, Wizderm Specialty Skin and Hair Clinic, Kolkata, West Bengal, India
| | - Dayamay Pal
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
| | - Projna Biswas
- Department of Dermatology, Calcutta National Medical College, Kolkata, West Bengal, India
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Acute Generalized Exanthematous Pustulosis: Pathogenesis, Genetic Background, Clinical Variants and Therapy. Int J Mol Sci 2016; 17:ijms17081214. [PMID: 27472323 PMCID: PMC5000612 DOI: 10.3390/ijms17081214] [Citation(s) in RCA: 111] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Revised: 07/06/2016] [Accepted: 07/13/2016] [Indexed: 01/25/2023] Open
Abstract
Acute generalized exanthematous pustulosis (AGEP) is a severe, usually drug-related reaction, characterized by an acute onset of mainly small non-follicular pustules on an erythematous base and spontaneous resolution usually within two weeks. Systemic involvement occurs in about 20% of cases. The course is mostly benign, and only in rare cases complications lead to life-threatening situations. Recent studies highlight the importance of genetic variations in interleukin-36 receptor antagonist gene (IL-36RN) in the pathogenesis of this disease. The physiopathology of AGEP remains unclear, but an involvement of innate and acquired immune cells together with resident cells (keratinocytes), which recruit and activate neutrophils via production of cytokines/chemokines such as IL-17, IL-36, granulocyte-macrophage colony-stimulating factor (GM-CSF), tumor necrosis factor alpha (TNFα) and chemokine (C-X-C motif) ligand 8 (CXCL8)/IL-8, has been postulated. Treatment is based on the removal of the causative drug, supportive care, infection prevention and use of potent topical or systemic steroids.
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Kostopoulos T, Krishna S, Brinster N, Ortega‐Loayza A. Acute generalized exanthematous pustulosis: atypical presentations and outcomes. J Eur Acad Dermatol Venereol 2014; 29:209-214. [DOI: 10.1111/jdv.12721] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 07/28/2014] [Indexed: 12/11/2022]
Affiliation(s)
- T.C. Kostopoulos
- Department of Dermatology Virginia Commonwealth University Medical Center Richmond VA USA
| | - S.M. Krishna
- Department of Dermatology Virginia Commonwealth University Medical Center Richmond VA USA
| | - N.K. Brinster
- Department of Dermatology Virginia Commonwealth University Medical Center Richmond VA USA
| | - A.G. Ortega‐Loayza
- Department of Dermatology Virginia Commonwealth University Medical Center Richmond VA USA
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Pavlos R, Mallal S, Ostrov D, Pompeu Y, Phillips E. Fever, rash, and systemic symptoms: understanding the role of virus and HLA in severe cutaneous drug allergy. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:21-33. [PMID: 24565765 DOI: 10.1016/j.jaip.2013.11.005] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Revised: 11/21/2013] [Accepted: 11/21/2013] [Indexed: 12/17/2022]
Abstract
Drug hypersensitivity syndromes such as abacavir hypersensitivity and the severe cutaneous adverse drug reactions have been associated with significant short- and long-term morbidity and mortality. More recently, these immunologically mediated and previously unpredictable diseases have been shown to be associated with primarily class I but also class II HLA alleles. The case of the association of HLA-B*57:01 and abacavir hypersensitivity has created a translational roadmap for how this knowledge can be used in the clinic to prevent severe reactions. Although many hurdles exist to the widespread translation of such HLA screening approaches, our understanding of how drugs interact with the major histocompatibility complex has contributed to the discovery of new models that have provided considerable insights into the immunopathogenesis of severe cutaneous adverse drug reactions and other T-cell-mediated drug hypersensitivity syndromes. Future translation of this knowledge will facilitate the development of preclinical toxicity screening to significantly improve efficacy and safety of drug development and design.
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Affiliation(s)
- Rebecca Pavlos
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia
| | - Simon Mallal
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Vanderbilt University School of Medicine, Nashville, Tenn
| | - David Ostrov
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, College of Medicine, Gainsville, Fla
| | - Yuri Pompeu
- Department of Pathology, Immunology and Laboratory Medicine, University of Florida, College of Medicine, Gainsville, Fla
| | - Elizabeth Phillips
- Institute for Immunology and Infectious Diseases, Murdoch University, Murdoch, Western Australia; Vanderbilt University School of Medicine, Nashville, Tenn.
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Kaya A, Yıldız S, Balkan İİ, Mert A, Eyvazov H, Bavunoglu I. Acute generalized exanthematous pustulosis after ceftriaxone use resembling sepsis. J Infect Chemother 2012; 18:112-4. [DOI: 10.1007/s10156-011-0297-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 08/15/2011] [Indexed: 10/17/2022]
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Current World Literature. Curr Opin Allergy Clin Immunol 2009; 9:386-90. [DOI: 10.1097/aci.0b013e32832eb836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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