FLUTTER, FEVER, AND A FIERY RED RASH: A CASE OF AGEP SECONDARY TO DILTIAZEM

Abstract

Introduction Acute Generalized Exanthematous Pustulosis (AGEP) is a severe cutaneous reaction that is characterized by acute formation of sterile pustules, accompanied with systemic features such as fever and leukocytosis. Case Description A 39-year old man with a past medical history of diastolic congestive heart failure presented to the hospital in an exacerbation. On day two of admission, he was diagnosed with new onset Atrial Flutter, and subsequently started on Diltiazem. On day ten of admission; patient noticed a rash in the intertriginous regions and the abdomen which spread to involve the face, chest and extremities. On examination, temperature was 102.7 degrees fahrenheit, heart rate 30 beats/min, blood pressure- 80’s systolic. Examination revealed an erythematous confluent rash with the presence of wide spread pustular lesions. His laboratory investigations were relevant for leukocytosis of 39.5 k/uL with 93% neutrophilia, and mild renal impairment. Skin biopsy demonstrated band like mild to moderate inflammatory infiltrate with scattered pigment laden macrophages. His AGEP validation score was 8 consistent with a definitive AGEP diagnosis. Diltiazem was stopped. He was started on topical triamcinolone cream twice daily. He had complete resolution of his rash within fifteen days of onset. Discussion Diltiazem is a medication widely used in the treatment of cardiac pathologies ie angina, atrial flutter/fibrillation and supraventricular tachycardia. AGEP has been documented as a rare side effect of this medication. This case highlights the need to increase awareness amongst clinicians of an uncommon adverse effect, as timely diagnosis can lead to complete resolution and favorable outcomes.