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Hung SI, Mockenhaupt M, Blumenthal KG, Abe R, Ueta M, Ingen-Housz-Oro S, Phillips EJ, Chung WH. Severe cutaneous adverse reactions. Nat Rev Dis Primers 2024; 10:30. [PMID: 38664435 DOI: 10.1038/s41572-024-00514-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/21/2024] [Indexed: 06/15/2024]
Abstract
Severe cutaneous adverse reactions (SCARs), which include Stevens-Johnson syndrome and toxic epidermal necrolysis, drug reaction with eosinophilia and systemic symptoms (also known as drug-induced hypersensitivity syndrome), acute generalized exanthematous pustulosis, and generalized bullous fixed drug eruption, are life-threatening conditions. The pathogenesis of SCARs involves T cell receptors recognizing drug antigens presented by human leukocyte antigens, triggering the activation of distinct T cell subsets. These cells interact with keratinocytes and various immune cells, orchestrating cutaneous lesions and systemic manifestations. Genetic predisposition, impaired drug metabolism, viral reactivation or infections, and heterologous immunity influence SCAR development and clinical presentation. Specific genetic associations with distinct SCAR phenotypes have been identified, leading to the implementation of genetic screening before prescription in various countries to prevent SCARs. Whilst systemic corticosteroids and conventional immunomodulators have been the primary therapeutic agents, evolving strategies, including biologics and small molecules targeting tumour necrosis factor, different cytokines, or Janus kinase signalling pathways, signify a shift towards a precision management paradigm that considers individual clinical presentations.
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Affiliation(s)
- Shuen-Iu Hung
- Cancer Vaccine and Immune Cell Therapy Core Laboratory, Department of Medical Research, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan
- Department and Institute of Pharmacology, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Maja Mockenhaupt
- Dokumentationszentrum schwerer Hautreaktionen (dZh), Department of Dermatology, Medical Center and Medical Faculty, University of Freiburg, Freiburg, Germany
| | - Kimberly G Blumenthal
- Division of Rheumatology, Allergy and Immunology, Department of Internal Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Riichiro Abe
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Mayumi Ueta
- Department of Ophthalmology, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Saskia Ingen-Housz-Oro
- Dermatology Department, AP-HP, Henri Mondor Hospital, Reference Centre for Toxic Bullous Diseases and Severe Drug Reactions TOXIBUL, Université Paris Est Créteil EpiDermE, Créteil, France
| | - Elizabeth J Phillips
- Center for Drug Safety and Immunology, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Wen-Hung Chung
- Department of Dermatology, Drug Hypersensitivity Clinical and Research Center, Chang Gung Memorial Hospital, Taipei/Linkou branches, and Chang Gung University, Taoyuan, Taiwan.
- Department of Dermatology, Chang Gung Memorial Hospital, Xiamen branch, Xiamen, China.
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2
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Leahy M, Byrne B, Markham T. Athena: Speciality Certificate Examination case for general dermatology and dermatology in primary health care. Clin Exp Dermatol 2023; 48:1069-1070. [PMID: 37177890 DOI: 10.1093/ced/llad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/27/2023] [Accepted: 05/10/2023] [Indexed: 05/15/2023]
Abstract
A 62-year-old man was referred to the emergency department with a 6-day history of a progressive pustular eruption; he had commenced ceftriaxone to treat suspected facial cellulitis 2 days prior. He had no significant past medical or dermatological history. This is a case of a rare severe cutaneous adverse reaction to a prescribed drug.
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Affiliation(s)
- Marion Leahy
- Department of Dermatology, University Hospital Galway, Galway, Ireland
| | - Berbie Byrne
- Department of Dermatology, University Hospital Galway, Galway, Ireland
| | - Trevor Markham
- Department of Dermatology, University Hospital Galway, Galway, Ireland
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3
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Parisi R, Shah H, Navarini AA, Muehleisen B, Ziv M, Shear NH, Dodiuk-Gad RP. Acute Generalized Exanthematous Pustulosis: Clinical Features, Differential Diagnosis, and Management. Am J Clin Dermatol 2023:10.1007/s40257-023-00779-3. [PMID: 37156992 PMCID: PMC10166469 DOI: 10.1007/s40257-023-00779-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 05/10/2023]
Abstract
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.
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Affiliation(s)
- Rose Parisi
- Albany Medical College, Albany, New York, NY, USA
| | - Hemali Shah
- Albany Medical College, Albany, New York, NY, USA
| | - Alexander A Navarini
- Department of Dermatology and Allergy, University Hospital of Basel, Basel, Switzerland
| | - Beda Muehleisen
- Department of Dermatology and Allergy, University Hospital of Basel, Basel, Switzerland
| | - Michael Ziv
- Department of Dermatology, Emek Medical Center, Afula, Israel
| | - Neil H Shear
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, M5S 1A1, Canada
| | - Roni P Dodiuk-Gad
- Department of Dermatology, Emek Medical Center, Afula, Israel.
- Division of Dermatology, Department of Medicine, University of Toronto, Toronto, ON, M5S 1A1, Canada.
- Department of Dermatology, Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, 3525433, Israel.
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4
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Wang S, Bai J, Qiao J. A Case Report of Possibly Related Acute Generalized Exanthematous Pustulosis with Staphylococcus pettenkoferi. Clin Cosmet Investig Dermatol 2023; 16:673-676. [PMID: 36960180 PMCID: PMC10029364 DOI: 10.2147/ccid.s399138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Accepted: 03/05/2023] [Indexed: 03/19/2023]
Abstract
Acute generalized exanthematous pustulosis (AGEP), an uncommon severe cutaneous adverse reaction, is believed to be a T cell-mediated hypersensitivity reaction, of which the most common cause is medication. However, infections have also been reported to be associated with AGEP. Here, we present a case of AGEP possibly related with Staphylococcus pettenkoferi.
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Affiliation(s)
- Su Wang
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
| | - Juan Bai
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
| | - Jianjun Qiao
- Department of Dermatology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, People’s Republic of China
- Correspondence: Jianjun Qiao; Juan Bai, Email ;
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5
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Tsurane K, Kaneko K, Yoshida K, Tanaka R, Sago H, Murashima A. Initiation of hydroxychloroquine therapy during pregnancy can cause adverse effects and alter pregnancy outcomes: a case of acute generalized exanthematous pustulosis induced by hydroxychloroquine in a patient with systemic lupus erythematosus. Mod Rheumatol Case Rep 2022:rxac089. [PMID: 36420890 DOI: 10.1093/mrcr/rxac089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/30/2022] [Accepted: 11/23/2022] [Indexed: 06/16/2023]
Abstract
Hydroxychloroquine is effective for treating a number of autoimmune diseases, including systemic lupus erythematosus. Hydroxychloroquine is generally safe and may be prescribed to pregnant women. Although current guidelines recommend initiating hydroxychloroquine when considering pregnancy, the drug can cause adverse effects such as acute generalized exanthematous pustulosis, which should be carefully evaluated. A 30-year-old pregnant woman with systemic lupus erythematosus at 16+5 gestational weeks was referred to our tertiary centre for persistent proteinuria and alopecia. Tacrolimus was initiated and the dose of prednisone was increased. At 20+3 weeks of gestation, hydroxychloroquine was administered to allow for a dose reduction of prednisolone. Proteinuria gradually improved as the pregnancy course stabilized. At 27+1 weeks of gestation, generalized pustular exanthema developed, presumably due to hydroxychloroquine. After analysis of the clinical course and skin lesions, she was considered to have either acute generalized exanthematous pustulosis or generalized pustular psoriasis. Despite discontinuing hydroxychloroquine, the skin lesions worsened dramatically, and infliximab therapy was required. After one course of infliximab treatment, exanthema gradually subsided. The final diagnosis was acute generalized exanthematous pustulosis, based on the clinical course and pathological findings. At 30 weeks, the pyothorax developed because of the pyogenic skin lesion and the compromised immune system, and long-term antibiotic therapy was required until 32+4 weeks, after which, she underwent caesarean section. Although introducing hydroxychloroquine is occasionally necessary during pregnancy, it is preferable to initiate hydroxychloroquine in the preconception period and not after pregnancy because of the possible adverse effect which can alter perinatal prognosis. Rheumatologists should consider the potential risks of hydroxychloroquine.
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Affiliation(s)
- Kotoi Tsurane
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kayoko Kaneko
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kazue Yoshida
- Division of Dermatology, National Center for Child Health and Development, Tokyo, Japan
| | - Ryo Tanaka
- Division of Dermatology, National Center for Child Health and Development, Tokyo, Japan
| | - Haruhiko Sago
- Division of Obstetrics, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Murashima
- Division of Maternal Medicine, Center for Maternal-Fetal, Neonatal and Reproductive Medicine, National Center for Child Health and Development, Tokyo, Japan
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6
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Odorici G, Schenetti C, Pacetti L, Schettini N, Gaban A, Mantovani L. Acute generalized exanthematous pustulosis due to hydroxichloroquine. Dermatol Ther 2022; 35:e15520. [PMID: 35434875 PMCID: PMC9111614 DOI: 10.1111/dth.15520] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 03/16/2022] [Accepted: 04/14/2022] [Indexed: 01/18/2023]
Affiliation(s)
- Giulia Odorici
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Cecilia Schenetti
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Lucrezia Pacetti
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Natale Schettini
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
| | - Alba Gaban
- Section of Anatomic Pathology, Department of Diagnostic Imaging and Experimental Medicine, University of Ferrara, S. Anna Hospital, Ferrara, Italy
| | - Lucia Mantovani
- Department of Medical Sciences, Section of Dermatology and Infectious Diseases, University of Ferrara, Ferrara, Italy
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Cravero K, Chakrala T, Shychuk A. Multisystem organ failure secondary to acute generalised exanthematous pustulosis (AGEP) with atypical presentation resembling septic shock. BMJ Case Rep 2022; 15:15/3/e247040. [PMID: 35232738 PMCID: PMC8889165 DOI: 10.1136/bcr-2021-247040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
- Karen Cravero
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Teja Chakrala
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Andrew Shychuk
- Internal Medicine, University of Florida College of Medicine, Gainesville, Florida, USA .,University of Florida, Gainesville, Florida, USA
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Daneshpazhooh M, Tavakolpour S, Salehi Farid A, Ebadi M, Nili A, Rashidian M, Mahmoudi H. Pustular eruption after biosimilar rituximab infusion: report of acute generalized exanthematous pustulosis in two patients with pemphigus. Int J Dermatol 2021; 61:e14-e17. [PMID: 34156705 DOI: 10.1111/ijd.15706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 03/30/2021] [Accepted: 05/25/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Maryam Daneshpazhooh
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Soheil Tavakolpour
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran.,Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Ali Salehi Farid
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mehrnoosh Ebadi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Nili
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Hamidreza Mahmoudi
- Autoimmune Bullous Diseases Research Center, Tehran University of Medical Sciences, Tehran, Iran
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