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A previously healthy 58-year-old woman presented to the emergency department with a 4-day history of a rapidly progressive generalized skin eruption. One week before, she was started on oral nystatin. On physical examination, she was afebrile, tachycardic, and hypotensive. She had generalized erythema with confluent pustules, pronounced in the intertriginous areas, including the axilla, creases of the elbow, inguinal folds, and medial thighs (Figure 1 A and B). Laboratory evaluation showed a leukocytosis with neutrophilia, elevated creatinine, and elevated lactate. The constellation of clinical findings was concerning for septic shock. The clinical differential diagnosis included acute generalized exanthematous pustulosis (AGEP) and pustular psoriasis. Skin biopsy showed subcorneal and intraepidermal pustules with papillary dermal edema and mixed dermal inflammation (Figure 2), which confirmed the diagnosis of AGEP, most likely caused by oral nystatin. Nystatin was discontinued, and she was treated with aggressive intravenous fluid hydration, full-body wet dressings, and oral prednisone, which led to resolution with desquamation over several days (Figure 1C and D).
Figure 1Discrete and confluent erythematous macules, papules, and patches with multiple pustules on the chest and abdomen (A) and lower extremities B, Desquamation with resolution of the drug eruption on the hands (C) and lower extremities (D).
Figure 2Subcorneal and spongiform pustules, mild dermal edema, and a mild superficial dermal perivascular lymphocytic infiltrate with neutrophils (20X original magnification, Hematoxylin-Eosin).
Acute generalized exanthematous pustulosis: clinical characteristics, etiologic associations, treatments, and outcomes in a series of 28 patients at Mayo Clinic, 1996-2013.
Clinicians need to recognize this entity because it is indistinguishable from pustular psoriasis, and they need to be aware of associated medications, as this drug reaction can be mistaken for septic shock.
Acute generalized exanthematous pustulosis: clinical characteristics, etiologic associations, treatments, and outcomes in a series of 28 patients at Mayo Clinic, 1996-2013.
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