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Background
This is a rare skin rash, usually secondary to a drug reaction. This disease is characterized by several features:
Numerous small, mostly nonfollicular pustules arising on an erythematous base
Intraepidermal or subcorneal pustules associated with dermal edema with focal necrosis of the keratinocytes
Fever (38C)
Blood neutrophil count >7000/mm3
Acute evolution with spontaneous resolution of pustules in less than 15 daysMost of the pustules last an average of 9-10 days and usually occurs within 2 days of drug exposure.
OUTLINE
EPIDEMIOLOGY CHARACTERIZATION INCIDENCE Rare
DISEASE ASSOCIATIONS CHARACTERIZATION ANTIBIOTICS Beta lactams
MacrolidesARTHROPOD BITE
Department of Dermatology, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
Acute generalized exanthematous pustulosis (AGEP) is a rare severe cutaneous adverse reaction caused mostly by drugs. Three of 22 AGEP cases (13.6%), recruited by us as part of two prospective multinational studies, occurred 24 to 48 hours after a spider bite.
We suggest that a spider bite is a possible trigger for AGEP.DRUGS Calcium channel blockers
Analgesics
Anti-pyreticsDEXAMETHASONE
Acute generalized exanthematous pustulosis induced by dexamethasone injection.Demitsu T, Kosuge A, Yamada T, Usui K, Katayama H, Yaoita H.
Department of Dermatology, Jichi Medical School, Tochigi-ken, Japan.
Dermatology 1996;193(1):56-8 Abstract quote A 52-year-old woman, without a history of psoriasis, developed a widespread, sterile pustular eruption on the trunk and extremities 2 days after subcutaneous injection of dexamethasone solution.
Skin biopsy revealed subcorneal pustules filled with neutrophils and moderate lymphohistiocytic infiltrate with a few eosinophils in the dermis. There was no evidence of vasculitis. Patch testing showed positive pustular reactions to dexamethasone solution. Histology of this pustule also resembled that of the original eruption.
To our knowledge, acute generalized exanthematous pustulosis due to corticosteroid has not been previously reported.
DILTIAZEM
Diltiazem-induced acute generalised exanthematous pustulosis.Wakelin SH, James MP.
Department of Dermatology, Royal Berkshire Hospital, Reading, UK.
Clin Exp Dermatol 1995 Jul;20(4):341-4 Abstract quote Pustulation is a major feature in several different dermatoses, and it may also occur as a manifestation of drug hypersensitivity. Acute generalized exanthematous pustulosis (AGEP) is an uncommon eruption characterized by acute, extensive formation of sterile pustules, fever and peripheral blood leucocytosis. It shares several clinical and histological features in common with pustular psoriasis. Most reported cases have been triggered by ingestion of broad spectrum antibiotics, particularly betalactams and macrolides. There is usually rapid resolution of the eruption on drug withdrawal.
We report the case of a 58 year-old woman who developed AGEP shortly after commencing treatment with the calcium channel blocker diltiazem hydrochloride. The eruption followed a biphasic course, and improved following treatment with systemic corticosteroids and methotrexate. AGEP appears to be a rare adverse cutaneous reaction to diltiazem, whereas a wide range of other skin eruptions have been reported more commonly with this drug.
DOXYCYCLINE
Acute generalized exanthematous pustulosis due to doxycycline.Trueb RM, Burg G.
Department of Dermatology, University Hospital, Zurich, Switzerland.
Dermatology 1993;186(1):75-8 Abstract quote Sterile epidermal neutrophilic pustulation can be observed in a variety of diseases. Though drug hypersensitivity is an uncommon cause, it is yet a known entity to be considered in the differential diagnosis of generalized pustulosis.
In a 40-year-old woman, who developed a generalized pustular eruption after starting on doxycycline therapy of bronchitis, the rash was concluded to be drug induced after exclusion of other pustular dermatoses.
Sensitization to doxycycline was demonstrated by in vitro lymphocyte testing and correlated with clinical drug hypersensitivity after recurrence of the pustular eruption on nonintentional rechallenge with doxycycline.
NYSTATIN Acute generalized exanthematous pustulosis following oral nystatin therapy: a report of three cases.
Kuchler A, Hamm H, Weidenthaler-Barth B, Kampgen E, Brocker EB.
Department of Dermatology, University Hospital, University of Wurzburg.
Br J Dermatol 1997 Nov;137(5):808-11 Abstract quote We report three cases of acute generalized exanthematous pustulosis (AGEP) following oral administration of nystatin. All cases showed similar clinical features and histopathological findings, and a delayed-type hypersensitivity to nystatin could be demonstrated in patch and prick testing.
Drug eruptions to nystatin are extremely rare, and, to our knowledge. AGEP has not been reported previously.
PARACETAMOL
Acute generalized exanthematous pustulosis induced by paracetamol. A case with severe hemodynamic disturbances.De Coninck AL, Van Strubarq AS, Pipeleers-Marichal MA, Huyghens LP, Suys ET, Roseeuw DI.
Department of Dermatology, Academic Hospital, Vrije Universiteit Brussel, Belgium.
Dermatology 1996;193(4):338-41 Abstract quote We report on a 28-year-old Bangladesh man with acute generalized exanthematous pustulosis, induced by paracetamol. The patient presented with an erythematous and pustular eruption after taking 1 tablet of paracetamol for a sore throat. After intravenous administration of propacetamol hydrochloride (which is a prodrug of paracetamol), the rash became worse, showing a toxic epidermal necrolysis-like appearance and the patient suffered from severe hemodynamic disturbances.
After discontinuation of propacetamol hydrochloride, the eruption cleared within 2 days. Prick testing performed in the patient revealed a positive reaction for propacetamol hydrochloride.
STI571 Acute generalized exanthematous pustulosis associated with STI571 in a patient with chronic myeloid leukemia.
Brouard MC, Prins C, Mach-Pascual S, Saurat JH.
Department of Dermatology, University Hospital, Geneva, Switzerland
Dermatology 2001;203(1):57-9 Abstract quote The tyrosine kinase inhibitor STI571 is a novel promising class of anticancer drugs. We report a case of cutaneous adverse reactions to STI571 in a young woman with blast crisis of chronic myeloid leukemia. She had first typical acute generalized exanthematous pustulosis mimicking mercury rash and then urticarial eruption.
We suggest that cell pathways mediated by some tyrosine kinases might be involved in the pathogenesis of these skin eruptions.
SALAZOSULFAPYRIDINE
Acute generalized exanthematous pustulosis induced by salazosulfapyridine in a patient with ulcerative colitis.Kawaguchi M, Mitsuhashi Y, Kondo S.
Department of Dermatology, Yamagata University School of Medicine, Japan.
J Dermatol 1999 Jun;26(6):359-62 Abstract quote We report a case of acute generalized exanthematous pustulosis (AGEP) induced by salazosulfapyridine in a patient with ulcerative colitis. A 26-year-old Japanese man, who had been receiving medical attention for ulcerative colitis for one year, presented with diffuse erythema and pustules on his face and trunk, malaise, and fever up to 39 degrees C one day after the administration of salazosulfapyridine.
A skin biopsy specimen disclosed intracorneal pustule composed of neutrophils and lymphohistiocytic infiltrate in the dermis. A drug lymphocyte stimulation test for salazoslufapyridine was positive, but the patch test was negative. Immunological mechanisms are suggested in the pathogenesis of psoriasis and ulcerative colitis.
We suspect that a similar immunological pathway played a role in the pathogenesis of AGEP appearing in psoriasis and ulcerative colitis.
TERBINAFINE
- Acute generalized exanthematous pustulosis induced by the antifungal terbinafine: case report and review of the literature.
Beltraminelli HS, Lerch M, Arnold A, Bircher AJ, Haeusermann P.
Department of Dermatology, Kantonsspital Basel, University of Basel, Petersgraben 4 CH-4031 Basel, Switzerland.
Br J Dermatol. 2005 Apr;152(4):780-3. Abstract quote
Cutaneous drug reactions occur with a frequency of 1-8% and can be higher for certain classes of drugs. They can range from mild morbilliform eruptions to more severe forms such as drug-hypersensitivity syndrome, toxic epidermal necrolysis or anaphylaxis.
Acute generalized exanthematous pustulosis (AGEP) is considered to be a clinical reaction pattern, which is induced in over 90% of the cases by systemic drugs. It is a rare presentation of an adverse drug reaction most frequently triggered by anti-infectious drugs. A high proportion of these cases have been attributed to aminopenicillins and macrolides.
We report a terbinafine-induced AGEP in a 68-year-old male confirmed by lymphocyte stimulation in vitro, and review the published cases induced by antimycotic drugs with special emphasis on terbinafine-triggered cases.VALDEOCOXIB
- Valdecoxib-associated acute generalized exanthematous pustulosis.
Byerly FL, Nelson KC, Granko RP, Morrell DS, Cairns BA.
Department of Surgery, North Carolina Jaycee Burn Center CB# 7600, University of North Carolina Hospitals, 101 Manning Drive, Chapel Hill, NC 27514, USA.
Burns. 2005 May;31(3):383-7 Abstract quote.
AGEP (acute generalized exanthematous pustulosis) is a relatively rare exfoliative skin syndrome consisting of generalized eruption of pustules in response to medication or infection. Because AGEP may have other systemic manifestations, such as renal failure, hyperthermia, lab abnormalities, and/or hemodynamic instability, it is important to make the distinction between AGEP and other life-threatening generalized skin diseases, such as toxic epidermal necrolysis (TEN).
Here we present a case of AGEP in response to valdecoxib, which has not previously been described in the literature. The patient presented with profound hypotension requiring fluid and vasopressor support and was referred to the burn service for treatment of TEN, but her skin lesions were inconsistent with this diagnosis. A dermatology consult was obtained and suggested a diagnosis of AGEP, which a biopsy confirmed.
TEN and AGEP present with similar history, types of associated drugs, and immunology. Both can be associated with antibiotics, non-steroidals, and anticonvulsants, but AGEP is more frequent with aminopenicillins, while TEN is associated more often with sulfonamide antibiotics.
Both disorders have a proposed T cell-mediated immune response, but they differ in the mechanism. A description of valdecoxib and its role as a sulfonamide in producing cutaneous reactions is also provided.
PATHOGENESIS CHARACTERIZATION GENERAL
Acute generalized exanthematous pustulosis, a clue to neutrophil-mediated inflammatory processes orchestrated by T cells.Britschgi M, Pichler WJ.
Division of Allergology, Clinic of Rheumatology and Clinical Immunology/Allergology, Inselspital, University of Bern, Bern, Switzerland.
Curr Opin Allergy Clin Immunol 2002 Aug;2(4):325-31 Abstract quote PURPOSE OF REVIEW: Circumstantial evidence exists that certain neutrophilic inflammatory processes are regulated by T cells, but how this occurs is not well understood. The present review presents data on how T cells may directly orchestrate a neutrophilic inflammation by specific release of the neutrophil-attracting chemokine CXCL8 (formerly known as interleukin-8).
RECENT FINDINGS: Acute generalized exanthematous pustulosis (AGEP) is an uncommon cutaneous eruption that is most often provoked by drugs, by acute infections with enteroviruses, or by mercury. It is characterized by acute, extensive formation of nonfollicular sterile pustules on an erythematous background, fever and elevated numbers of blood neutrophils. Involvement of T cells in drug-induced AGEP was suggested by positive patch tests and lymphocyte transformation tests. Moreover, drug-specific CD4+ and CD8+ T cells could be isolated and propagated in vitro from patch test sites and blood from AGEP patients. Their main characteristic is a high level of CXCL8 production.
SUMMARY: T cells are involved even in some neutrophil-rich inflammatory responses, and they may orchestrate the immune reaction directly by high CXCL8 production or indirectly via interleukin-17 production, which induces CXCL8 production in various cell types. AGEP serves as a valuable model for characterizing T cells with a particular function - namely production of CXCL8 - leading to neutrophilic inflammation. It is tempting to speculate that elucidation of this pathomechanism will help to improve our understanding of similar neutrophilic eruptions (e.g. pustular psoriasis) and may reveal new targets for pharmacotherapeutic interventions in such diseases.
PATCH TESTING
- Cross-Comparison of Patch Test and Lymphocyte Proliferation Responses in Patients With a History of Acute Generalized Exanthematous Pustulosis.
Girardi M, Duncan KO, Tigelaar RE, Imaeda S, Watsky KL, McNiff JM.
From the Departments of *Dermatology and daggerImmunobiology, Yale University School of Medicine, New Haven, Connecticut; and double daggerYale-New Haven Hospital, New Haven, Connecticut.
Am J Dermatopathol. 2005 Aug;27(4):343-346. Abstract quote
An adverse cutaneous reaction to a systemically administered drug may rarely manifest as acute generalized exanthematous pustulosis (AGEP). Several recent reports have documented positive patch test results in patients with a history of AGEP, while two have demonstrated drug-specific in vitro lymphocyte proliferative responses. These findings suggest that drug-specific T cells mediate AGEP.
We describe two patients with a history of AGEP who each demonstrated positive patch test results specific for the inciting drug: Patient #1 to the antibiotic metronidazole, and Patient #2 to the calcium channel-blocker diltiazem. Histologic examination of biopsy specimens taken from the patch test sites of these patients revealed spongiotic dermatitis and perivascular lymphocytes consistent with a delayed-type hypersensitivity reaction, rather than demonstrating subcorneal neutrophilic pustules more typical of AGEP. In vitro testing by measuring peripheral T cell proliferative responses to chemically purified drug correlated with the clinical response.
In a direct cross-comparison, patch test results were shown to correlate with in vitro lymphocyte proliferative responses in two patients with a history of AGEP to different drugs. These findings provide additional evidence that the pathogenesis of AGEP involves a T cell-mediated immune response.
A systemic reaction to patch testing for the evaluation of acute generalized exanthematous pustulosis.
Mashiah J, Brenner S.
Department of Dermatology, Tel Aviv Sourasky Medical Center, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
Arch Dermatol. 2003 Sep;139(9):1181-3. Abstract quote
BACKGROUND: Patch tests are considered safe but adverse reactions have been reported.
OBSERVATIONS: A case of acute generalized exanthematous pustulosis (AGEP) provoked by a patch test with acetaminophen is described. Of special interest are the negative patch test results obtained with the offending drug. The case is discussed against the background of the putative mechanisms of AGEP and the reported systemic reactions to patch testing for AGEP.
CONCLUSIONS: To our knowledge, this is the first report in the English-language literature of a generalized AGEP-like reaction caused by patch tests carried out to determine the drug eliciting AGEP.
LABORATORY/
RADIOLOGIC/
OTHER TESTSCHARACTERIZATION RADIOLOGIC LABORATORY MARKERS DRUG LYMPHOCYTE STIMULATION TEST
Drug induced acute generalized exanthematous pustulosis.Katagiri K, Takayasu S.
Department of Dermatology, Oita Medical University, Japan.
J Dermatol 1996 Sep;23(9):623-7 Abstract quote A 62-year-old woman with diabetic triopathy developed widespread erythematous macules, numerous pustules, and a high fever after she underwent electric coagulation for vitreous hemorrhage. She was administered several drugs at that time.
After discontinuation of the drugs, the eruption disappeared, and the fever returned to normal within two weeks. A positive patch test with isepamicin sulfate highly suggested that the symptoms described above were due to drug allergy. Cadralazine, which was positive in the drug lymphocyte stimulation test (DLST), could not be excluded from the causative drugs. A false-positive DLST with ofloxacin was confirmed by an accidental challenge test.
To our knowledge, this is the first report of acute generalized exanthematous pustulosis due to isepamicin sulfate and/or cadralazine.
GROSS APPEARANCE/
CLINICAL VARIANTSCHARACTERIZATION GENERAL
Acute generalized exanthematous pustulosis. Analysis of 63 cases.Roujeau JC, Bioulac-Sage P, Bourseau C, Guillaume JC, Bernard P, Lok C, Plantin P, Claudy A, Delavierre C, Vaillant L, et al.
Department of Dermatology, University of Creteil, France.
Arch Dermatol 1991 Sep;127(9):1333-8 Abstract quote We retrospectively analyzed 63 observations collected in nine French departments of dermatology of an acute pustular dermatosis, recently named in the French literature acute generalized exanthematous pustulosis (AGEP). Even though 11 of these cases occurred in patients with a history of psoriasis, AGEP appeared distinct from pustular psoriasis based on several slight pathologic differences, drug induction in most cases, and a more acute course of fever and pustulosis, with rapid spontaneous healing.
We, therefore, suggest that AGEP is a reaction pattern, perhaps favored by a "psoriatic background." The most frequent causes of AGEP seem to be drug reactions, acute infections with enteroviruses, and hypersensitivity to mercury. With 55 (87%) of 63 cases attributed to drugs in this series, AGEP should be added to the list of cutaneous adverse drug reactions. Among drug-induced skin eruptions, AGEP is remarkable by its short time to onset after the administration of the suspected drug (less than 24 hours in half of our cases) and the great predominance (80%) of antibiotics as causative agents.
It is suggested that some cases previously reported as "drug-induced pustular psoriasis" were in fact AGEP.
Acute generalized exanthematous pustulosis.Beylot C, Doutre MS, Beylot-Barry M.
Department of Dermatology, Hopital du Haut Leveque, France.
Semin Cutan Med Surg 1996 Dec;15(4):244-9 Abstract quote Acute generalized exanthematous pustulosis (AGEP) is now a well-known clinical entity, characterized by acute onset with associated fever, and numerous non-follicular pin-head sterile pustules on erythematous background.
The biopsy evidences subcorneal pustules resembling those of pustular psoriasis. However, polymorphic aspects such as pseudo-erythema multiforme purpuric lesions, and edema are often associated, and with the rapid self-healing course of this impressive pustulosis, allow the differential diagnosis with pustular psoriasis. Most cases of AGEP are drug induced, particularly by antibiotics and mainly beta-lactams.
However, a number of other drugs, of which the list is increasing, may be responsible. Few cases are related to other causative factors such as viral infections or ultraviolet radiation.
HISTOLOGICAL TYPES CHARACTERIZATION GENERAL Acute generalized exanthematous pustulosis (AGEP) – A clinical reaction pattern
Alexis Sidoroff, etal.
J Cutan Pathol 2001;28 (3):113-119 Abstract quote
Background: A wide range of diseases or reactions can cause pustular eruptions of the skin. In this spectrum there seems to be a subgroup with characteristic clinical features and a typical course which is mostly caused by drugs for which the term acute generalized exanthematous pustulosis (AGEP) has been established.
Objective: To describe the clinical features of AGEP.
Methods: The authors’ experience from a multinational epidemiological study on severe cutaneous adverse reactions and a comprehensive review of the literature were used to provide an overview of the disease and it’s possible causes. An algorithm for validating cases which was established for this study is also presented.
Results: AGEP typically presents with at least dozens of non follicular sterile pustules occurring on a diffuse, edematous erythema predominalty in the folds and/or on the face. Fever and elevated blood neutrophils are common. Histopathology typically shows spongiform subcorneal and/or intraepidermal pustules, a marked edema of the papillary dermis, and eventually vasculitis, eosinophils and/or focal necrosis of keratinocytes. Onset is acute, most often following drug intake, but viral infections can also trigger the disease. Pustules resolve spontaneously in less than 15 days.
Conclusion: The diagnosis AGEP should be considered in cases of acute pustular rashes and detection of the causative drug should be strived for. Knowledge of the clinical features and usual course of this disease can often prevent unnecessary therapeutical measures.
VARIANTS
DIFFERENTIAL DIAGNOSIS KEY DIFFERENTIATING FEATURES GENERAL
Pustular skin disorders: diagnosis and treatment.Mengesha YM, Bennett ML.
Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA.
Am J Clin Dermatol 2002;3(6):389-400 Abstract quote The differential diagnosis for pustular skin disorders is extensive. The distribution of the lesions and the age of the patient are characteristics that may provide strong clues to the etiology of cutaneous pustular eruptions.
In adults, generalized pustular dermatoses include pustular psoriasis, Reiter's disease and subcorneal pustular dermatosis. Medications can cause generalized pustular eruptions, such as in the case of acute generalized exanthematous pustulosis; or more localized reactions, such as acneiform drug eruptions, which usually involve the face, chest and back. Localized pustular eruptions are seen on the hands and feet in adults with pustulosis palmaris et plantaris and acrodermatitis continua (both of which may be variants of psoriasis); on the face in patients with acne vulgaris, rosacea, and perioral dermatitis; and on the trunk and/or extremities in patients with folliculitis. A seperate condition known as eosinophilic folliculitis occurs in individuals with advanced human immunodeficiency disease. Severely pruritic, sterile, eosinophilic pustules are found on the chest, proximal extremities, head and neck. Elevated serum immunoglobulin E and eosinophilia are often concurrently found. In neonates, it is especially important to make the correct diagnosis with respect to pustular skin disorders, since pustules can be a manifestation of sepsis or other serious infectious diseases. Generalized pustular eruptions in neonates include erythema toxicum neonatorum and transient neonatal pustular melanosis, both of which are non-infectious. Pustules are seen in infants with congenital cutaneous candidiasis, which may or may not involve disseminated disease. Ofuji's syndrome is an uncommon generalized pustular dermatosis of infancy with associated eosinophilia. As in adults, neonates and infants may develop acne or scabies infestations.
In this article, we review the most common pustular dermatoses and offer a systematic approach to making a diagnosis. We also report the most up-to-date information on the treatment of these various cutaneous pustular conditions.
PUSTULAR PSORIASIS PUSTULOSIS ACUTA GENERALISATA
Pustulosis acuta generalisata is a post-streptococcal disease and is distinct from acute generalized exanthematous pustulosis.Auer-Grumbach P, Pfaffenthaler E, Soyer HP.
Department of Dermatology, University of Graz, Austria.
Br J Dermatol 1995 Jul;133(1):135-9 Abstract quote Generalized pustular eruptions with fever present a diagnostic and therapeutic problem. Based on a case of pustulosis acuta generalisata and a review of the literature, this entity can be regarded as an exclusively post-streptococcal disorder with an elevated antistreptolysin titre. It has a distinct clinical presentation of isolated pustules on normal skin, predominantly in an acral location.
We propose criteria for the clear separation of this disease from acute generalized exanthematous pustulosis and from pustular psoriasis.
SUBCORNEAL PUSTULAR DERMATOSIS OF SNEDDON AND WILKINOSON SWEET'S SYNDROME TOXIC EPIDERMAL NECROLYSIS
PROGNOSIS AND TREATMENT CHARACTERIZATION PROGNOSTIC FACTORS TREATMENT Usually self-limited and resolves spontaneously with discontinuation of the drug May consider systemic prednisone therapy Henry JB. Clinical Diagnosis and Management by Laboratory Methods. Twentieth Edition. WB Saunders. 2001.
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Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
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Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.
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