Acute generalized exanthematous pustulosis presumed to be caused by acetaminophen

Hyeong Woo Kim; Yong Sun Choi; Jung Ho Won; Jae Min Lee; Jin Young Heo; Jung Ah Choi; Mi-Jung Oh

doi:10.4168/aard.2017.5.1.52

Journal List > Allergy Asthma Respir Dis > v.5(1) > 1059294

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Kim, Choi, Won, Lee, Heo, Choi, and Oh: Acute generalized exanthematous pustulosis presumed to be caused by acetaminophen

Case Report

Allergy, Asthma & Respiratory Disease 2017; 5(1): 52-55.

Published online: 31 January 2017

DOI: https://doi.org/10.4168/aard.2017.5.1.52

Acute generalized exanthematous pustulosis presumed to be caused by acetaminophen

Hyeong Woo Kim, Yong Sun Choi, Jung Ho Won, Jae Min Lee, Jin Young Heo, Jung Ah Choi, Mi-Jung Oh

Department of Internal Medicine, Bundang Jesaeng General Hospital, Seongnam, Korea.

Correspondence to: Mi-Jung Oh. Department of Internal Medicine, Bundang Jesaeng General Hospital, 20 Seohyeon-ro 180beon-gil, Bundang-gu, Seongnam 13590, Korea. Tel: +82-31-779-0200, Fax: +82-31-779-0897, mjoh@dmc.or.kr

Received 15 June 2016 Revised 9 August 2016 Accepted 11 August 2016

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/).

Abstract

Acute generalized exanthematous pustulosis (AGEP) is a severe and rare disease usually related to drug eruption. AGEP is induced by drugs in over 90% of cases with antibiotics being the most common. It is characterized by a fever and a pustular eruption on erythematous skin with acute onset and without follicular localization. Acetaminophen is commonly used as an antipyretic and analgesic. Acetaminophen has been reported to be an uncommon cause of AGEP. We report a 79-year-old woman presenting with fever and erythematous maculopapular eruptions on the trunk with sterile pustules arising upon the use of acetaminophen for back pain. Leukocytosis and elevated C-reactive protein levels were noted on the laboratory examination. The histopathological examination of the skin biopsy specimen showed intraepidermal pustule formation with superficial perivascular lymphocytic infiltration, including eosinophils, and extensive red blood cell extravasation. The lesions were resolved with discontinuation of acetaminophen and use of systemic corticosteroid. We report a case of AGEP probably caused by acetaminophen.

Keywords: Acute generalized exanthematous pustulosis, Acetaminophen, Drug eruption

Figures and Tables

Fig. 1

There are multiple nonfollicular, pustular lesions on an erythematous background on the back.

Fig. 2

The patient became afebrile the very next day of stopping of paracetamol.

Fig. 3

Histologic examination shows intraepidermal pustule formation with superficial perivascular lymphocytic infiltration including eosinophils and extensive red blood cell extravasation (A: H&E, ×100; B: H&E, ×200).

Table 1

Scores for the diagnosis of AGEP (proposed by the EuroSCAR group)2

	Score
Morphology
Pustules
Typical	+2
Compatible	+1
Insufficient	0
Erythema
Typical	+2
Compatible	+1
Insufficient	0
Distribution/pattern
Typical	+2
Compatible	+1
Insufficient	0
Postpustular desquamation
Yes	+1
No/insufficient	0
Course
Mucosal involvement
Yes	−2
No	0
Acute onset
Yes-2	0
No
Resolution of pustules and erythema ≤ 15 days
Yes	0
No	−4
Fever (≥ 38℃)
Yes	+1
No	0
Blood neutrophil count (≥ 7,000 cells/mm³)
Yes	+1
No	0
Histopathological analysis
Other diseases	−10
Not significant/no anatomopathological examination	0
Polymorphonuclear cell exocytosis	+1
No subcorneal and/or intraepidermal spongiosis or unspecified	+2
Pustules with papilledema or subcorneal and/or intraepidermal
Spongiosis or unspecified, pustules without papilledema
Subcorneal and/or intraepidermal spongiform pustules with papilledema	+3

AGEP, acute generalized exanthematous pustulosis.

Interpretationn (score): 0, not AGEP; 1–4, AGEP is possible; 5–7, AGEP is probable; 8–12, AGEP is established.

^*Typical: typical morphology. ^†Compatible: morphology is not typical but strongly suggestive. ^‡Insufficient: lesions cannot be evaluated (due to advanced stage of development).

Adapted from Sidoroff et al. J Cutan Pathol 2001;28:113-9, with permission of John Wiley and Sons.2

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ORCID iDs: Mi-Jung Oh
https://orcid.org/http://orcid.org/0000-0002-7827-8411
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