Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature

Tools for Etiologic Diagnosis of Drug-Induced Allergic Conditions

Drug hypersensitivity reactions are a serious concern in clinical practice because they can be severe and result in lifelong sequelae. An accurate diagnosis and identification of the culprit drug is essential to prevent future reactions as well as for the identification of safe treatment alternatives. Nonetheless, the diagnosis can be challenging. In vivo and in vitro tests can be helpful, although none are conclusive; therefore, the tests are not usually performed in isolation but as part of a diagnostic algorithm. In addition, some in vitro tests are only available in research laboratories, and standardization has not been fully accomplished. Collaborating research is needed to improve drug hypersensitivity reaction diagnosis. In this review, we update the current available in vivo and in vitro tools with their pros and cons and propose an algorithm to integrate them into clinical practice.

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.

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.

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.

Antifungal hypersensitivity reactions and cross-reactivity patterns

PURPOSE OF REVIEW

The goal of this article is to provide an updated understanding and evidence-based approach where possible for antifungal hypersensitivity. This includes recognition of clinical phenotype, implications for cross-reactivity and diagnostic, and management strategy for immediate and delayed hypersensitivity reactions.

RECENT FINDINGS

Antifungal hypersensitivity reactions can be classified according to their latency (immediate or delayed) and clinical phenotype. The majority of the cases described in the literature are delayed T-cell mediated reactions of various severities but immediate reactions consistent with non-Immunoglobulin E (IgE)-mediated mast cell activation and IgE-mediated reactions have also been described. Ancillary information such as skin testing, drug challenge and ex vivo experimental approaches can aid causality assessments and inform antifungal class cross-reactivity, which help optimize antifungal prescribing and stewardship.

SUMMARY

This review will update the clinician on mechanisms of drug hypersensitivity as well as providing a structured approach to the recognition, diagnosis and management of antifungal hypersensitivity reaction.

Etiopathological and Clinical Study of Acute Generalized Exanthematous Pustulosis: Experience from a Tertiary Care Hospital in North India

Background:

Acute generalized exanthematous pustulosis (AGEP) is a type of severe cutaneous adverse reaction that is characterized by the rapid development of nonfollicular, sterile pustules on an erythematous base.

Objectives:

The aim of our study was to enroll all cases of AGEP reporting to our department over a period of one year and to find out the clinical and etiological profile of the patients.

Materials and Methods:

All the patients reporting to our department with clinical features suggestive of AGEP were enrolled for the study. Careful history and examination were done to rule out other causes of pustular eruptions, which can resemble AGEP. AGEP validation score of the EuroSCAR study group was used to establish the diagnosis.

Results:

A total of 16 patients were enrolled during the study period of one year. The majority of the patients were females with a mean age of 28.41 ± 12.2 years. Twelve (75%) of the patients had a history of drug intake while 4 (25%) had developed AGEP following an insect bite. Penicillins were the causative factor in five patients followed by cephalosporins in three patients, nonsteroidal anti-inflammatory drugs (NSAIDs) in 2 patients, and terbinafine in 1 patient. Tetanus toxoid was responsible for the development of AGEP in one patient. The insect bites were all spider bites.

Conclusion:

AGEP is a rare type of severe cutaneous adverse drug reaction.We encountered 16 patients of AGEP over a period of one year. An important cause of AGEP was spider bite in our study group.

A novel whole blood based method for lymphocyte transformation test in drug allergies

Drug allergies pose a great deal of danger for the patients. It hinders effective treatment procedures in hospitalized patients. Moreover, it complicates the symptoms due to the allergic reactions of the immune system. Allergic reactions may arise against any medication including antibiotics and chemotherapeutics. Therefore, it is crucial to assess the sensitization pattern of the patients to culprit drug(s) before retreatment with the same or similar drug, or in order to confirm/exclude a suspected drug hypersensitivity reaction. In vivo and in vitro tests are performed in the evaluation of patients. Current methods of in vitro drug allergy evaluations rely on time consuming and expensive methods. Ficoll separation of peripheral blood mononuclear cells, their activation with stimulants in the presence of the drug of interest, CD69 or CD25 or BrdU or radioactive thymidine analysis of the cells after a couple of days of incubation is an excessively elaborate work and also uneconomical. Moreover, it requires a great deal of expertise to interpret the results. Here, we are reporting a new whole blood based lymphocyte transformation test method that does not require ficoll separation, CD69, CD25, BrdU and radioactive thymidine analysis. Thanks to the color change in the whole blood itself one can easily determine the allergic reaction to a certain drug. This new method is less time consuming, more economical and easy to apply.

Distinguishing pustular psoriasis and acute generalized exanthematous pustulosis on the basis of plasmacytoid dendritic cells and MxA protein

BACKGROUND

Distinguishing acute generalized exanthematous pustulosis (AGEP) and pustular psoriasis (PS) can be challenging. Staining for plasmacytoid dendritic cells, or PDCs (producer of IFN-α/β), and MxA (an IFN-α/β inducible protein) may help discriminate these entities.

METHODS

Forty-three cases of AGEP and PS were compiled from two academic institutions. All cases were examined for CD123+ PDCs, eosinophils, acanthosis, papillomatosis, suprapapillary plate thinning, tortuous dilated capillaries, single necrotic keratinocytes, papillary dermal edema, vasculitis, eosinophil exocytosis, intraepidermal pustules, and subcorneal pustules. A subset of cases (n = 26) was stained for MxA.

RESULTS

Perivascular and intraepidermal PDCs, dilated tortuous vessels, and MxA expression in the dermal inflammatory infiltrate were significantly (P < 0.05) in favor of a diagnosis of PS. The absence of PDCs and presence of eosinophils favored a diagnosis of AGEP (P < 0.05).

CONCLUSIONS

We found compelling evidence for the use of CD123 to highlight PDCs in these cases. The presence of PDCs and expression of MxA in dermal inflammatory infiltrate, as well as absence of eosinophils and presence of tortuous dilated capillaries favored a diagnosis of PS. Expression of MxA in the dermal infiltrate corresponds with a Th1 pathway in PS and may indicate a Th1 component in the early initial phase of AGEP.

Rare drug allergies: Review on prevalence and test procedures

This paper gives a review on rare hypersensitivity reactions (including allergies) to drugs. Pathogenesis, allergy tests and possible therapeutic options are discussed by presenting examples out of the following group of drugs: antiinfectious (i.e. chinolones, telaprevir), oncological (i.e. platin-based cytostatics), immunologic (i.e. cetuximab, omalizumab), others (i.e. glucocorticosteroids). Usually there is no standardized allergologcial work-up procedure. Testing must therefore take into consideration previous experiences from other authors and on general recommendations.

[Terbinafine : Drug-induced lupus erythematodes and triggering of psoriatic skin lesions]

Based on the technical information that oral terbinafine must be used with caution in patients with pre-existing psoriasis or lupus erythematosus, the literature was summarized. Terbinafine belongs to the drugs able to induce subcutaneous lupus erythematosus (SCLE)-with a relatively high risk. The clinical picture of terbinafine-induced SCLE may be highly variable and can also include erythema exsudativum multiforme-like or bullous lesions. Thus, differentiation of terbinafine-induced Stevens-Johnson syndrome or toxic epidermal necrolysis may be difficult. Therefore, terbinafine should be prescribed with caution in patients who show light sensitivity, arthralgias, positive antinuclear antibodies or have a history of SLE or SCLE. Case reports include wide-spread, but mostly nonlife-threatening courses, which did not require systemic therapy with steroids or antimalarials in every case. Terbinafine is also able to induce or to aggravate psoriasis. The latency period seems to be rather short (<4 weeks). Terbinafine therefore is not first choice if a systemic therapy with antimycotics is indicated in a patient with psoriasis or psoriatic diathesis. Azole derivatives according to the guidelines may be used as an alternative.

Acute generalized exanthematous pustulosis x Von Zumbusch's pustular psoriasis: a diagnostic challenge in a psoriatic patient

Severe cutaneous drug reactions include a wide spectrum of clinical manifestations ranging from mild morbilliform cutaneous rash, to severe forms of hypersensitivity. Special attention is given in this report to the acute generalized exanthematous pustulosis (AGEP), induced in 90% of cases by the use of systemic drugs, especially aminopenicillins and macrolides. The incidence of the disease is low, 1-5 cases per million patients / year. The main differential diagnosis is Von Zumbusch's Pustular Psoriasis. The prognosis is generally good and the disease self limited, after withdrawal of the triggering drug. In this report the authors describe a case of AGEP, triggered by ceftriaxone in a patient with psoriasis vulgaris.

[Acute generalized exanthematous pustulosis]

CLINICAL FEATURES

Acute generalized exanthematous pustulosis (AGEP) is a reaction pattern mostly caused by drugs. It is characterized by the rapid occurrence of dozens to thousands pinhead-sized, non-follicular, sterile pustules on a slightly edematous erythematous base, commonly with accentuation in the major flexures and usually accompanied by a facial edema, fever and leukocytosis. Histology reveals spongiform subcorneal and/or intraepidermal pustules, an inflammatory infiltrate consisting of neutrophils and often eosinophils and frequently a marked edema of the papillary dermis.

TRIGGERS

Even if in single case reports a large number of drugs has been described as triggers for AGEP, larger studies have revealed a list with an elevated risk to cause the reaction which includes antibacterial agents like ampicillin/amoxicillin, quinolones, pristinamycin, anti-infective sulfonamides, the antimycotic drug terbinafine, (hydroxy)chloroquine, and diltiazem. In some cases infections have been reported as triggers.

CLINICAL COURSE, PROGNOSIS AND TREATMENT

AGEP is an acute and--especially in patients with concomitant diseases--sometimes severe reaction. Withdrawal of the causative agent usually leads to a rapid and complete resolution--even without further specific therapy.

Fluconazole-induced acute generalized exanthematous pustulosis

Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction and is usually caused by drugs. It is characterized by fever and acute, extensive occurrence of disseminated sterile pustules, accompanied by fever, malaise and peripheral blood leucocytosis. There have been several reports to date of AGEP following exposure to antifungals. In particular, terbinafine is included in the list of the agents conferring the highest risk of AGEP. The authors report the case of a 70-year-old male patient who developed AGEP shortly after commencing treatment with fluconazole, which has been reported in association with AGEP in a single case report. To our knowledge, this is the first reported case of AGEP associated with positive fluconazole patch test.

Acute generalized exanthematous pustulosis: A rare side effect of a common over-the-counter drug, Acetylsalicylic acid

Acute generalized exanthematous pustulosis is an uncommon cutaneous reaction characterized by sudden onset of generalized non-follicular aseptic pustules. It is most often secondary to drugs but causes as varied from viral infection to insect bites are reported. A case report of a 48-year-old male who developed pustular eruptions after taking acetylsalicylic acid is reported here. Clinicians need to be aware of this entity when dealing with pustular rash as this rare side effect of a very common drug is both, easy to miss and easy to manage.

Acute generalized exanthematous pustulosis associated with terbinafine: a case report

A 27-year-old male patient who has used oral terbinafine for two weeks was admitted to our outpatient clinic for non-follicular millimetric pustules on erythematous and edematous different-sized plaques on his trunk and flexural areas. He was diagnosed with acute generalized exanthematous pustulosis (AGEP) because of terbinafine use in the light of history, clinical and histopathological findings. An AGEP is a rare and severe pustular reaction usually triggered by systemic drug intake. Approximately, 2.3% of the patients having oral terbinafine have been reported to develop cutaneous adverse effects. Although terbinafine is a commonly used medicine, it must be considered that it may cause severe adverse reactions.

Acute generalized exanthematous pustulosis caused by diltiazem

Acute generalized exanthematous pustulosis is clinically characterized by fever, pruritus and an acute pustular eruption. It can be described as having an abrupt onset and then spontaneous resolution occurs shortly after the start of symptoms, and there is usually only a single episode. Most cases have been triggered by the ingestion of drugs. Diltiazem hydrochloride is a calcium channel blocker that is commonly used for treating hypertension and angina. This drug was found to be the responsible agent in our current patient. There have been 9 such case reports in the English medical literature, yet this is the first such report in the Korean medical literature. We present the case of a 51-year-old male who experienced an acute generalized exanthematous pustulosis due to diltiazem hydrochloride and we review the relevant literature.

Acute generalized exanthematous pustulosis in a patient after stem cell transplantation

BACKGROUND

a severe generalized pustular eruption occurred several months after allogeneic hematopoietic stem cell transplantation for multiple myeloma in a patient being treated with antibiotics for respiratory infection. Neither he nor his donor had a history of psoriasis.

METHODS

the patient was treated with drug withdrawal and administration of cyclosporine and methylprednisolone without improvement; later, acitretin and methylprednisolone were used successfully. The eruption slowly subsided, and therapy was discontinued. Four months later, the patient experienced a recurrent severe pustular eruption associated with fever and leukocytosis, and the same treatment was used successfully again.

RESULTS AND CONCLUSION

the patient has not experienced relapses in the ensuing 3 years. Acute generalized exanthematous pustulosis is a rare cutaneous adverse reaction triggered most commonly by drugs with a tendency to resolve spontaneously. The surprisingly prolonged, refractory, and relapsing course of the eruption in our patient might be due to the immune alteration and the polypharmacologic therapy after stem cell transplantation.

Severe cutaneous adverse reactions: acute generalized exanthematous pustulosis, toxic epidermal necrolysis and Stevens-Johnson syndrome

Most drug hypersensitivity reactions show skin symptoms. The most severe cutaneous manifestations include pustular and bullous skin eruptions. These 2 manifestations can lead to acute generalized exanthematous pustulosis or Stevens-Johnson syndrome and toxic epidermal necrolysis. These complications are rare, but should be known to any doctor prescribing drugs because they are life threatening and early stoppage of treatment is mandatory.

Acute generalized exanthematous pustulosis induced by itraconazole: an immunological approach

Acute generalized exanthematous pustulosis (AGEP) is an uncommon disease, which presents as a nonfollicular erythematous sterile pustular eruption. More than 90% of the cases are induced by adverse drug reactions, often triggered by anti-infectious systemic drugs. We report a case of itraconazole-induced AGEP in a 22-year-old man, with an assessment of his cytokine/chemokine production and drug-specific cell reactivity. We found that AGEP, like other T cell-mediated drug eruptions, alters the immunological status of the patient, probably favouring T-cell activation, recruitment and regulation. Few cases of itraconazole-induced AGEP have been described in the literature, and to our knowledge, this is the first report in which the cellular immunological features are assessed.

Acute generalized exanthematous pustulosis: report of 12 cases and literature review

BACKGROUND

Acute generalized exanthematous pustulosis is an acute pustular eruption occurring after infection and/or drug ingestion, with spontaneous cure after a single eruption.

AIM

To communicate a series of cases of acute generalized exanthematous pustulosis.

METHODS

A retrospective analysis was performed on cases of acute generalized exanthematous pustulosis, observed between 1993 and 2006 at the Dermatology Department, Hospital General de Occidente, Jalisco, Mexico.

RESULTS

Twelve patients were included, with a predominance of male patients and a mean age of 28 years. The most common cause was drugs, detected in 83% of cases, and most of these were a result of anticonvulsants and antimicobials. The most frequent symptoms were itching, present in all cases, and fever, present in 92% of cases.

CONCLUSIONS

Acute generalized exanthematous pustulosis is considered to be a distinct clinical and histopathologic entity. Because of its self-resolving character, early recognition can help to avoid unnecessary diagnostic studies and treatments.

Update on terbinafine with a focus on dermatophytoses

Since terbinafine was introduced on the world market 17 years ago, it has become the leading antifungal for the treatment of superficial fungal infections, aided by unique pharmacologic and microbiologic profiles. This article reviews mode of action, antimycotic spectrum and disposition profile of terbinafine. It examines the data, accumulated over 15 years, on the comparative efficacy of terbinafine (vs griseofulvin, itraconazole, fluconazole) in the management of the infections for which it is primarily indicated (eg, dermatophytoses) and provides a brief discussion on its use for the treatment of non-dermatophyte infections. Finally, the available data on the newest topical and systemic formulations are introduced.

Role of epidermal dendritic cells in drug-induced cutaneous adverse reactions

Drug-induced adverse reactions (ADR) include any undesirable pharmacological effect that occurs following drug administration at therapeutic doses. The appearance of ADR significantly limits the use of drugs in as much as their clinical symptoms may range from very mild discomfort such as cutaneous rash, up to very severe, or even fatal tissue necrolysis such as the Stevens Johnson syndrome.One of the most frequently involved organ during ADR is the skin. Drug-induced cutaneous reactions (CDR) incidence is variable but they may appear in 2-3% of ambulatory patients, and it may increase to 10-15% when patients are hospitalized, or even be as high as 60% when co morbidity includes the presence of virus, bacteria, or parasites.Due to the fact that skin is one of the organs most frequently involved in ADR, in this work we analyze and propose a mechanism by which epidermal dendritic cells operating as the sentinels of the skin neuro-immune-endocrine system may contribute to CDR via either immunogenic or tolerogenic immune responses towards drugs, whenever they are administered topic or systemically.

[Adverse drug reactions and the skin--from trivial to fire signal]

Adverse drug reactions are a common medical problem. Especially hypersensitivity reactions are mostly impressive and unsettling due to their nature of being not dose-dependent and non-predictable. Clinical manifestations of the skin comprise manifold appearances from mild macular exanthems to bullous eruptions, and urticaria, angioedema to anaphylaxis. Systemic hypersensitivity reactions can affect nearly all internal organs and cells. Characteristic clinical danger signs for severe allergic drug reactions, for immediate type as well as for delayed type manifestations, help to recognise the incipient allergic drug reaction, to stop the further administration of the potential elicitor/allergen and to start therapeutic actions. It is essential for the success of a further allergologic work-up of such reactions to describe and document accurately the morphologic characteristics of the skin and other organ manifestations and the exact time course of medication intake and development of the clinical adverse reaction. This facilitates the choice of adequate diagnostic measures and the interpretation of the respective results.

Acute Generalized Exanthematous Pustulosisafter Ingestion of Lacquer Chicken

Acute generalized exanthematous pustulosis (AGEP) is an acute pustular eruption characterized by multiple small, sterile, non-follicular pustules on an erythematous and edematous base, usually accompanied by fever and neutrophilia. It is attributed to systemic drugs in over 90% of cases, mainly β-lactam and macrolide antimicrobials. Viral infections, mercury exposure, Ginkgo biloba, and spider bites may occasionally cause the condition. We report a rare case of AGEP induced by intake of lacquer chicken in a 40-year-old man.

[Diagnostic methods for confirming drug-allergy--the lymphocyte transformation test in dermatology]

Recognizing the adverse drug reactions and confirming the role of the drug causing the symptoms is a great challenge for a medical team. The aim of this article is to review the diagnostic methods for confirming drug-allergy and to evaluate the lymphocyte transformation test according to dermatological aspect. Lymphocyte transformation test relies on the observation that specific T-cells divide and expand after encountering the antigen. T-cell sensitization is measured by 3H-thymidine uptake in dividing cells. The main advantage of this test is its applicability with many different drugs in different immune reactions, as drug-specific T-cells are almost always involved in drug hypersensitivity reactions. Its disadvantage is that the test is cumbersome and technically demanding. The method is not unequivocally accepted, it is necessary to carry out a systematic evaluation of its sensitivity and specificity to make the test more widely appreciated. Despite of its deficits, the lymphocyte transformation test plays an important role in diagnosing drug-hypersensitivities.

Acute generalized exanthematous pustulosis from dalteparin

Heparins are widely used for the prophylaxis and treatment of venous thromboembolism. Several types of immunologically mediated reactions to heparins are reported, among them delayed-type hypersensitivity reactions with erythematous, infiltrated itchy plaques at injection sites. We describe a female patient, whose localized reaction from dalteparin was followed by a generalized rash presenting as acute generalized exanthematous pustulosis. Subcutaneous provocation testing showed cross-reactions to enoxaparin, certoparin, reviparin, nadroparin, danaparoid, fondaparinux, but not to pentosan polysulfate. The danaparoid and in a lesser extent the nadroparin patch showed pustules. Within the next day, a generalized rash developed. The upper aspect of her trunk was highly affected and showed discrete pustules. Despite the fact that low molecular-weight heparins are widely prescribed, this is, to our knowledge, the first observation of a pustular drug eruption attributable to this class of substances.

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

BACKGROUND

Acute generalized exanthematous pustulosis (AGEP) is a disease characterized by the rapid occurrence of many sterile, nonfollicular pustules usually arising on an oedematous erythema often accompanied by leucocytosis and fever. It is usually attributed to drugs.

OBJECTIVES

To evaluate the risk for different drugs of causing AGEP.

PATIENTS AND METHODS

A multinational case-control study (EuroSCAR) conducted to evaluate the risk for different drugs of causing severe cutaneous adverse reactions; the study included 97 validated community cases of AGEP and 1009 controls. Results Strongly associated drugs, i.e. drugs with a lower bound of the 95% confidence interval (CI) of the odds ratio (OR) > 5 were pristinamycin (CI 26-infinity), ampicillin/amoxicillin (CI 10-infinity), quinolones (CI 8.5-infinity), (hydroxy)chloroquine (CI 8-infinity), anti-infective sulphonamides (CI 7.1-infinity), terbinafine (CI 7.1-infinity) and diltiazem (CI 5.0-infinity). No significant risk was found for infections and a personal or family history of psoriasis (CI 0.7-2.2).

CONCLUSIONS

Medications associated with AGEP differ from those associated with Stevens-Johnson syndrome or toxic epidermal necrolysis. Different timing patterns from drug intake to reaction onset were observed for different drugs. Infections, although possible triggers, played no prominent role in causing AGEP and there was no evidence that AGEP is a variant of pustular psoriasis.

Recognition and Management of Severe Cutaneous Drug Reactions

Cutaneous drug reactions are among the most common types of adverse drug reactions. This article focuses on the recognition and management of severe cutaneous drug eruptions, including the drug-hypersensitivity syndrome, serum sickness-like reaction, acute generalized exanthematous pustulosis, Stevens-Johnson syndrome, and toxic epidermal necrolysis. Cutaneous reactions are considered severe when they can result in serious skin damage or involve multiple organs. Some of these reactions can cause significant morbidity or death. Each may be confounded by diagnostic difficulties, confusion in ascertaining causality, and treatment challenges.

Akute generalisierte exanthematische Pustulose bei nachgewiesener Typ-IV-Allergie

Acute generalized exanthematous pustulosis (AGEP) is characterized by an acute disseminated eruption of multiple, non-follicular pustules. In addition, it can be associated with fever, elevated erythrocyte sedimentation rate, and leukocytosis. The pathogenesis of AGEP is still unknown; however, medications appear a likely cause in most cases. We report on 3 patients with AGEP demonstrating characteristic clinical and histologic features after taking amoxicillin, ampicillin, or diltiazem. All patients had positive patch test reactions to the suspected drugs.

Acute generalized exanthematous pustulosis caused by morphine, confirmed by positive patch test and lymphocyte transformation test

Morphine, an opium alkaloid, frequently causes side effects such as hyperhidrosis and facial flushing, but serious cutaneous adverse drug reactions are seldom observed. Best known are urticaria, erythema, and pruritus; sometimes pseudoallergic anaphylactoid reactions, and blisters are reported.