International Journal of Clinical & Medical Images

An 80-year-old woman presented with fever and a generalized, erythematous pruritic eruption of 3 days duration. Four days prior to the eruption, she was treated with terbinafine 250 mg po daily for onychomycosis. She denied any recent viral illness. There was no personal or family history of skin disease. On examination, her temperature was 38.50C. Dermatological examination revealed generalized, symmetrical erythematous macules/patches and multiple, scattered small nonfollicular pustules with surrounding erythema on the trunk and upper extremities. Mucosal surfaces were spared. Nikolsky sign was negative. Her white blood cell count was 17.6 x 109/L. Gram staining and bacterial culture of the pustule were negative. A punch biopsy taken from one of the lesions revealed subcorneal and intraepidermal pustules, widespread spongiosis, and neutrophilic perivascular infiltration. Acute generalized exanthematous pustulosis (AGEP) is a rare and potentially severe cutaneous adverse reaction most commonly in response to drug therapy. The main culprit drugs are antibiotics (macrolides, beta-lactam antibiotics, sulphonamides), calcium-channel blockers (diltiazem), antifungal agents (terbinafine, ketoconazole), antipyretics (paracetamol), and antimalarials (hydroxychloroquine, chloroquine). AGEP usually occurs within 5 days of starting the offending medication. AGEP is a type IV hypersensitivity reaction. Drug specific CD4+ and CD8+ T cells play a crucial role. Viral and bacterial infections and hypersensitivity reaction to mercury have also been incriminated. Clinically, AGEP manifests with an acute onset of widespread bilateral symmetrical edematous erythematous macules/patches studded with numerous small scattered non-follicular sterile pustules. The eruption is often pruritic or burning and accompanied by fever and leukocytosis. AGEP can occur at any age. The sex ratio is approximately equal. The disease is generally self-limited and resolves within 15 days once the offending agent is withdrawn. Treatment is mainly symptomatic. Mortality occurs mainly in elderly patients with significant comorbidities.