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Acute Generalized Exanthematous Pustulosis in Children

Acute Generalized Exanthematous Pustulosis in Children We treated 5 children (Table 1) with pustular eruptions consistent with acute generalized exanthematous pustulosis (AGEP) over the past 5 years. Four of them had no history of medication exposure, providing support for a possible infectious pathogenesis. The fifth patient (No. 5), who had end-stage renal failure, developed a pustular eruption consistent with AGEP at the end of a 3-week course of intraperitoneal vancomycin hydrochloride. He had also received labetalol hydrochloride intermittently during the preceding month. The pustules, erythema, and subsequent desquamation resolved approximately 17 days after the vancomycin therapy was discontinued and 7 days after the labetalol therapy was discontinued. Patient 2 had undergone measles, mumps, rubella, diptheria, pertussis, tetanus, and pneumococcal vaccinations (which did not have any mercurial component) 2 days before developing an asymptomatic generalized pustular eruption with hand swelling. One week earlier, he had developed influenza-like symptoms with diarrhea, which had since resolved. The other 3 patients had a history of rhinorrhea (patient 1, Figure 1), non–group A β-hemo-lytic streptococcal tonsillitis (patient 3), or otitis media (patient 4) before the pustular rash consistent with AGEP appeared. View LargeDownload Five Male Patients With Acute Generalized Exanthematous Pustulosis Figure 1. View LargeDownload Generalized papulopustules scattered on the trunk and extremities (patient 1). In 3 of our 5 patients, erythematous papules accompanied the more typical small pustular lesions. One patient (No. 5) had targetoid lesions of the palms at the onset of the rash. In another patient (No. 2), hand swelling occurred before the pustules developed. One patient (No. 3, Figure 2) underwent a biopsy, which revealed superficial and deep perivascular infiltrates composed of polymorphonuclear leukocytes, lymphocytes, and histiocytes. Mild spongiosis was noted at the dermoepidermal junction, with polymorphonuclear leukocytes in intraepidermal vesicles. Figure 2. View LargeDownload Grouped pustules on the inner thigh area (patient 3). Typical AGEP is characterized by the acute onset of fever and generalized erythroderma topped with superimposed small, nonfollicular, sterile pustules.1,2 However, fever is occasionally absent.2 The pustules resolve spontaneously within 4 to 10 days, with a characteristic pattern of punctate desquamation. Acute generalized exanthematous pustulosis has rarely been described in children.1 β-Lactam and macrolide antibiotics1,2 are thought to be the most common drug triggers, although AGEP has been described in association with other medications.2 One of the patients in our series may have developed AGEP in reaction to the administration of labetalol, which has not been previously described, but the reaction began when he was also taking vancomycin, an already-recognized medication trigger. Much less commonly, viral agents and mercury exposure have been suggested in the literature as other possible triggers in both adults and children.2-4 Correia et al5 described a patient who developed AGEP after undergoing pneumococcal vaccination. Our second patient had undergone measles, mumps, rubella, diphtheria, pertussis, tetanus, and pneumococcal vaccinations 2 days before the rash developed, suggesting vaccination exposure as the possible trigger, but he also had developed an influenza-like illness 1 week earlier, which indicates that an infectious agent may have been responsible. Acute generalized exanthematous pustulosis is uncommon in children and may be atypical in its presentation. In our series, the administration of medication was not associated with onset of the eruption in 4 of the 5 cases, suggesting that viral infections (and perhaps vaccinations) are the most frequent triggers of AGEP in the pediatric population. The authors have no relevant financial interest in this article. Correspondence: Dr Mancini, Division of Dermatology, Children's Memorial Hospital, Box 107, 2300 Children's Plaza, Chicago, IL 60614 (amancini@northwestern.edu). References 1. Meadows KPEgan CAVanderhooft S Acute generalized exanthematous pustulosis, an uncommon condition in children: case report and review of the literature Pediatr Dermatol. 2000;17399- 402PubMedGoogle ScholarCrossref 2. Roujeau JCBioulac-Sage PBourseau C et al. Acute generalized exanthematic pustulosis: analysis of 63 cases Arch Dermatol. 1991;1271333- 1338PubMedGoogle ScholarCrossref 3. Rouchouse BBonnefoy MPallot BJacquelin LDimoux-Dime GClaudy AL Acute generalized exanthematous pustulosis and viral infection Dermatologica. 1986;173180- 184Google ScholarCrossref 4. Haro-Gabaldon VSanchez-Sanchez-Vizcaino JRuiz-Avila P et al. Acute generalized exanthematous pustulosis with cytomegalovirus infection Int J Dermatol. 1996;35735- 737PubMedGoogle ScholarCrossref 5. Correia ONunes JPVaz-da-Silva MJPires SBranbao FMesquita-Guimaraes J Acute generalized exanthematous pustulosis after pneumococcal vaccine [letter] Dermatology. 1993;187217PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Dermatology American Medical Association

Acute Generalized Exanthematous Pustulosis in Children

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Publisher
American Medical Association
Copyright
Copyright © 2004 American Medical Association. All Rights Reserved.
ISSN
0003-987X
eISSN
1538-3652
DOI
10.1001/archderm.140.9.1172
Publisher site
See Article on Publisher Site

Abstract

We treated 5 children (Table 1) with pustular eruptions consistent with acute generalized exanthematous pustulosis (AGEP) over the past 5 years. Four of them had no history of medication exposure, providing support for a possible infectious pathogenesis. The fifth patient (No. 5), who had end-stage renal failure, developed a pustular eruption consistent with AGEP at the end of a 3-week course of intraperitoneal vancomycin hydrochloride. He had also received labetalol hydrochloride intermittently during the preceding month. The pustules, erythema, and subsequent desquamation resolved approximately 17 days after the vancomycin therapy was discontinued and 7 days after the labetalol therapy was discontinued. Patient 2 had undergone measles, mumps, rubella, diptheria, pertussis, tetanus, and pneumococcal vaccinations (which did not have any mercurial component) 2 days before developing an asymptomatic generalized pustular eruption with hand swelling. One week earlier, he had developed influenza-like symptoms with diarrhea, which had since resolved. The other 3 patients had a history of rhinorrhea (patient 1, Figure 1), non–group A β-hemo-lytic streptococcal tonsillitis (patient 3), or otitis media (patient 4) before the pustular rash consistent with AGEP appeared. View LargeDownload Five Male Patients With Acute Generalized Exanthematous Pustulosis Figure 1. View LargeDownload Generalized papulopustules scattered on the trunk and extremities (patient 1). In 3 of our 5 patients, erythematous papules accompanied the more typical small pustular lesions. One patient (No. 5) had targetoid lesions of the palms at the onset of the rash. In another patient (No. 2), hand swelling occurred before the pustules developed. One patient (No. 3, Figure 2) underwent a biopsy, which revealed superficial and deep perivascular infiltrates composed of polymorphonuclear leukocytes, lymphocytes, and histiocytes. Mild spongiosis was noted at the dermoepidermal junction, with polymorphonuclear leukocytes in intraepidermal vesicles. Figure 2. View LargeDownload Grouped pustules on the inner thigh area (patient 3). Typical AGEP is characterized by the acute onset of fever and generalized erythroderma topped with superimposed small, nonfollicular, sterile pustules.1,2 However, fever is occasionally absent.2 The pustules resolve spontaneously within 4 to 10 days, with a characteristic pattern of punctate desquamation. Acute generalized exanthematous pustulosis has rarely been described in children.1 β-Lactam and macrolide antibiotics1,2 are thought to be the most common drug triggers, although AGEP has been described in association with other medications.2 One of the patients in our series may have developed AGEP in reaction to the administration of labetalol, which has not been previously described, but the reaction began when he was also taking vancomycin, an already-recognized medication trigger. Much less commonly, viral agents and mercury exposure have been suggested in the literature as other possible triggers in both adults and children.2-4 Correia et al5 described a patient who developed AGEP after undergoing pneumococcal vaccination. Our second patient had undergone measles, mumps, rubella, diphtheria, pertussis, tetanus, and pneumococcal vaccinations 2 days before the rash developed, suggesting vaccination exposure as the possible trigger, but he also had developed an influenza-like illness 1 week earlier, which indicates that an infectious agent may have been responsible. Acute generalized exanthematous pustulosis is uncommon in children and may be atypical in its presentation. In our series, the administration of medication was not associated with onset of the eruption in 4 of the 5 cases, suggesting that viral infections (and perhaps vaccinations) are the most frequent triggers of AGEP in the pediatric population. The authors have no relevant financial interest in this article. Correspondence: Dr Mancini, Division of Dermatology, Children's Memorial Hospital, Box 107, 2300 Children's Plaza, Chicago, IL 60614 (amancini@northwestern.edu). References 1. Meadows KPEgan CAVanderhooft S Acute generalized exanthematous pustulosis, an uncommon condition in children: case report and review of the literature Pediatr Dermatol. 2000;17399- 402PubMedGoogle ScholarCrossref 2. Roujeau JCBioulac-Sage PBourseau C et al. Acute generalized exanthematic pustulosis: analysis of 63 cases Arch Dermatol. 1991;1271333- 1338PubMedGoogle ScholarCrossref 3. Rouchouse BBonnefoy MPallot BJacquelin LDimoux-Dime GClaudy AL Acute generalized exanthematous pustulosis and viral infection Dermatologica. 1986;173180- 184Google ScholarCrossref 4. Haro-Gabaldon VSanchez-Sanchez-Vizcaino JRuiz-Avila P et al. Acute generalized exanthematous pustulosis with cytomegalovirus infection Int J Dermatol. 1996;35735- 737PubMedGoogle ScholarCrossref 5. Correia ONunes JPVaz-da-Silva MJPires SBranbao FMesquita-Guimaraes J Acute generalized exanthematous pustulosis after pneumococcal vaccine [letter] Dermatology. 1993;187217PubMedGoogle ScholarCrossref

Journal

Archives of DermatologyAmerican Medical Association

Published: Sep 1, 2004

Keywords: child,pustulosis, acute generalized exanthematous

References