Acute Generalized Exanthematous Pustulosis (AGEP)

Acute Generalized Exanthematous Pustulosis (AGEP) Clinical Features:

• Acute-onset fever & generalized scarlatiniform erythema.
• Associated with many small, sterile, nonfollicular pustules (small blisters filled with white/yellow fluid).
• Typically the rash starts on the face or in the armpits & groin - later becoming more widespread.
• The onset of AGEP is usually within 2 days of exposure to the responsible medication.
• AGEP is more common in patients who have a personal or family history of psoriasis.
• AGEP may have a presentation similar with generalised pustular psoriasis or subcorneal pustular dermatosis.
• AGEP is less serious than these conditions, has more marked hyperleukocytosis with neutrophilia & eosinophilia, & clears up much more quickly.

Aetiology (General):

• Most cases are caused by drugs (primarily antibiotics) often in the first few days of administration.
• Most common drugs are beta-lactam antibiotics, macrolides, & mercury
• Some cases caused by viral infections, mercury exposure, or UV radiation.
• Viral infections - Epstein-Barr virus & cytomegalovirus.
• Spider bites have also been implicated in some cases.

Aetiology (Specific) Less Common: [1]

• A - acetaminophen, ACE inhibitors (eg, captopril, ramipril), allopurinol
• B - bufexamac, buphenine
• C - calcium channel blockers, carbamazepine, carbutamide, celecoxib, chloramphenicol, clindamycin, co-trimoxazole, clobazam, cyclins (eg, tetracycline), cytarabine
• D - diltiazem
• F - famotidine, furosemide
• G - gemfibrozil, ginkgo biloba, glyburide
• H - hydrochlorothiazide, hydroxychloroquine
• I - ibuprofen, imatinib, imipenem, isoniazid, IV contrast dye
• L - lopinavir-ritonavir
• M - mexiletine, morphine
• N - nadoxolol, nifedipine, nystatin
• O - olanzapine
• P - phenytoin, pipemidic acid, piperazine, pseudoephedrine, pyrimethamine
• Q - quinidine
• R - ranitidine, rifampicin
• S - salbutiamine, sertraline, simvastatin, streptomycin
• T - terbinafine, thallium
• V - vancomycin

Investigations:

• FBC - increased neutrophils are usually found.
• Skin Biopsy - subcorneal pustules filled with neutrophils.
• Patch Testing - may be helpful to determine allergy. [2]

Prognosis:

• AGEP typically resolves spontaneously & rapidly.
• Fever & pustules lasting ~ 7-10 days followed by desquamation over a few days.

Treatment:

• Most important to stop exposure to the provoking agent.
• Symptomatic relief - analgesics, moisturisers, topical corticosteroids, oral antihistamines.

References:

• 1 - Thakor P, Padmanabhan M, Johnson A, Pararajasingam T, Thakor S, Jorgensen W. Ramipril-induced generalized pustular psoriasis: case report and literature review. Available at http://www.ncbi.nlm.nih.gov/sites/entrez/19531936.
• 2 - Barbaud A. Drug patch testing in systemic cutaneous drug allergy. Toxicology. Apr 15 2005;209(2):209-16.
• "Drug Eruptions" eMedicine (link)

Tags: AGEP - Drug Eruption - Exanthem - Fever - Patch Testing - Pustular Psoriasis - Pustules - Pustulosis
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