POSTSURGICAL ACUTE GENERALIZED EXANTHEMATOUS PUSTULOSIS: TIMING IS EVERYTHING

Abstract

<h3>Introduction</h3> Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous adverse reaction commonly caused by antibiotics. <h3>Case Description</h3> A 62-year-old male was evaluated for a painful and burning pustular eruption three days after a hip arthroplasty. Medication timeline was notable for intraoperative (3 days prior) receipt of cefazolin, dexamethasone, hydromorphone, ropivacaine, and tranexamic acid. Two days prior, he received oxycodone, ondansetron, omeprazole, sennosides, and dexamethasone. One day prior to presentation he received meloxicam and aspirin. Physical examination revealed confluent erythema studded with pinhead-sized sterile pustules on the bilateral thighs, under arms (Figure 1A), and trunk. Complete blood count with differential showed mild neutrophilia (7.59; ref 1.56-6.45 × 10⁻⁹/L) and a complete metabolic panel was within normal limits. Histopathology of a punch biopsy from the right thigh revealed subcorneal pustules with epidermal spongiosis, mild papillary dermal edema and a mixed perivascular infiltrate (Figure 1B) consistent with AGEP. He was instructed to avoid all beta-lactams, non-steroidal antiinflammatory agents (NSAIDs), and steroids. The eruption completely resolved within 10 days of avoidance measures and antihistamines. There were plans to perform patch testing to cefazolin, prednisone, and dexamethasone. Unfortunately, the patient was lost to follow-up. <h3>Discussion</h3> AGEP is diagnosed clinically and confirmed by a skin biopsy. Patch testing may be utilized to evaluate for the culprit agent; but when this is not available, the timeline between medication exposure and index reaction may aid in causal agent identification. The median time from exposure to onset of AGEP is 1 day for antibiotics versus 11 days for all other medications.