Rare case of phenytoin induced acute generalized exanthematous pustulosis with cerebellar syndrome

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.

Antiepilepsy drugs and the immune system

OBJECTIVE

To alert physicians about the peculiar adverse effects of antiepilepsy drugs (AEDs) on the immune system.

DATA SOURCES

PubMed literature during the past 25 years.

STUDY SELECTIONS

Reports and review articles on the hypersensitivities of AEDs and their effect on immunity.

RESULTS

AEDs have significant effects on the immune system in the form of hypersensitivity or immune suppression. IgE-mediated reactions can be urticaria, angioedema, bronchospasm, or anaphylaxis. Non-IgE-mediated reactions, more commonly associated with aromatic AEDs, can be in the form of nonspecific rashes or serious reactions, such as Stevens-Johnson syndrome, toxic epidermal necrolysis, drug rash with eosinophilia and systemic symptom syndrome, and acute generalized exanthematous pustulosis. Because of strong genetic predispositions for certain AEDs in causing severe reactions, HLA analysis before initiation of the drug is advised in certain populations. Immunoglobulin levels can be reduced to various degrees, particularly by carbamazepine, valproate, phenytoin, levetiracetam, zonisamide, and lamotrigine. Spontaneous return to normal levels can be rapid or take months to a few years, and intravenous immunoglobulin supplementation may be needed. Cellular effects can be in the form of cytopenias, inhibition of lymphocyte function, or cytokine dysregulation.

CONCLUSION

When prescribing AEDs, physicians should pay special attention to their potential adverse effects on immunity or hypersensitivity, which can be severe and even fatal. For early recognition and intervention, monitoring such patients is necessary. The cornerstone of management is discontinued use of the suspected medication and avoidance of drugs of similar structure, particularly among members of the aromatic group.

Acute Generalized Exanthematous Pustulosis: Pathogenesis, Genetic Background, Clinical Variants and Therapy

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.