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

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


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.

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

  Typical +2
  Compatible +1
  Insufficient 0
  Typical +2
  Compatible +1
  Insufficient 0
  Typical +2
  Compatible +1
  Insufficient 0
 Postpustular desquamation
  Yes +1
  No/insufficient 0
 Mucosal involvement
  Yes −2
  No 0
 Acute onset
  Yes-2 0
 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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