27989 An unusual presentation of acute generalized exanthematous pustulosis (AGEP) in pregnancy

Abstract

A 39-year-old female at 23 weeks’ gestation presented with a four-day history of diffuse pustules that developed acutely on her abdomen and rapidly spread. She denied any associated symptoms, personal or family history of skin disorders, and review of systems was negative. Her medications included omeprazole for gastroesophageal reflux disease and a prenatal vitamin. Physical examination revealed enumerable pustules over the abdomen and flanks with background erythema; erythematous macules and papules coalescing into edematous plaques with enumerable overlying pustules on the anterior lower extremities; scattered erythematous macules on the upper extremities; and rare pustules on the chest and neck. The differential diagnosis included acute generalized exanthematous pustulosis (AGEP), pustular psoriasis of pregnancy (PPP), and pemphigoid gestationis. Two punch biopsies were performed for hematoxylin and eosin stain (H&E) and direct immunofluorescence (DIF) respectively. Biopsy for H&E demonstrated modest spongiosis with spotty microfoci of neutrophilic exocytosis, tiny parakeratotic mounds with entrapped neutrophils, and scattered neutrophils in the papillary dermis with rare eosinophils. DIF demonstrated patchy segmental granular IgM deposition along the dermoepidermal junction and granular C3 deposition along the dermoepidermal junction. Laboratory workup including complete blood count, comprehensive metabolic panel, ionized calcium, parathyroid hormone, anti-neutrophilic antibody, anti-histone antibodies, anti-double-stranded DNA antibodies, and anti-Smith antibodies were unremarkable. Triamcinolone 0.1% ointment twice daily and discontinuation of omeprazole resulted in the complete resolution of the pustules. Given the rapid improvement with topical steroids and discontinuation of omeprazole in conjunction with the lack of systemic symptoms, the patient was diagnosed with AGEP secondary to omeprazole.