Severe acute generalized exanthematous pustulosis with toxic epidermal necrolysis-like desquamation: A case series of 8 patients

Acute generalised exanthematous pustulosis and herpes simplex virus: a case of possible overlap

Acute generalised exanthematous pustulosis (AGEP) is a rare cutaneous disorder that presents with numerous non-follicular, pinpoint sterile pustules on a background of oedematous erythema that can coalesce, leading to desquamation. 90% of cases are triggered by medications, most often with antibiotics as the culprit. However, other triggers including viral infection have also been reported. Herpes simplex virus (HSV) as a viral trigger has not been previously explored. Here, we present a case of AGEP caused by bupropion, followed by a second presentation of assumed acute limited exanthematous pustulosis in the setting of disseminated HSV. This case may represent the first report of AGEP and HSV overlap. It also presents the interesting dilemma of differentiating AGEP and disseminated HSV (which can present similarly) as well as determining appropriate treatment and the utility versus risk of systemic steroid administration.

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.