ImportanceTrimethoprim-sulfamethoxazole (TMP-SMX) hypersensitivity reaction, ranging from circulatory shock to aseptic meningitis and respiratory failure, is a potentially life-threatening condition with dermatologic relevance.ObjectiveTo describe the mucocutaneous findings and clinical features of TMP-SMX hypersensitivity reaction.Design, Setting, and ParticipantsThis was a retrospective case series study of 7 patients who developed a characteristic rash, hemodynamic changes, and end-organ dysfunction after treatment with TMP-SMX at a large university hospital system during January 2013 to March 2022.ExposuresTreatment with TMP-SMX within 2 weeks of the reaction.Main Outcome and MeasuresDescriptions of the condition, including the demographic information of the affected population, the reaction timeline, and mucocutaneous and clinical features.ResultsThe cohort comprised 7 patients (median [range] age, 20 [15-66] years; 4 female and 3 male). The most common mucocutaneous findings were generalized sunburn-like erythema without scale, conjunctivitis, and mild facial and acral edema. Three patients had previous exposure to TMP-SMX and developed symptoms in 1 day or less, while those without prior exposure presented from 4 to 11 days after drug initiation. Among the 7 patients, 6 had fever, 7 had hypotension, and 7 had tachycardia. All patients had lymphopenia and evidence of end-organ dysfunction with either kidney or liver involvement. Median (range) time to resolution was 72 (48-96) hours.Conclusions and RelevanceThis retrospective case series indicates that SCoRCH (sudden conjunctivitis, lymphopenia, and rash combined with hemodynamic changes) should be considered in the differential diagnosis of patients presenting with acute generalized sunburn-like erythema, conjunctivitis, systemic symptoms, and hemodynamic changes in the setting of recent TMP-SMX use.
Background: Acute generalized exanthematous pustulosis (AGEP) is a severe pustular drug eruption with rare reports of haemodynamic instability. Objective: To describe the clinical characteristics, management, and outcomes of patients with AGEP-associated haemodynamic instability. Methods: This retrospective case series identified adult patients diagnosed with AGEP who had haemodynamic instability from November 2012 to February 2020 that were seen at two academic teaching hospitals with roles as a burn centre and tertiary referral centre at the University of Texas Southwestern Medical Center in Dallas, TX USA. Patients with a discharge diagnosis of AGEP that had haemodynamic instability during their eruption were included. Patients with a history of psoriasis, presentations thought to be a flare of generalized pustular psoriasis, or concurrent infection during eruption were excluded. AGEP with haemodynamic instability was characterized by degree of hypotension, dermatologic phenotype at time of dermatologic consultation, and management approach. Results: This study included 19 patients with AGEP-associated haemodynamic instability (mean age, 52 years; age range, 29-76 years; 11 (58%) female). Patients were classified on a spectrum of haemodynamic instability; three had sustained hypotension, 10 had hypotension with organ dysfunction, and six had shock. Patients with AGEP-associated haemodynamic instability had a range of dermatologic phenotypes at initial consultation: subtle exanthematous eruption with minimal pustules, typical eruption with pustules and flexural predominance, and severe eruption with features of Stevens-Johnson syndrome. Both topical and systemic corticosteroids were used for treatment of several patients. Of the patients that required vasopressors and received systemic steroids, the majority were off vasopressors within 24 h of steroid initiation.
Conclusion: Approximately 22% of patients presenting with AGEP to a tertiary referral center had haemodynamic instability. Clinicians should beThis is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.
Acute generalized exanthematous pustulosis (AGEP) is a rapidly evolving adverse drug reaction with a characteristic presentation of diffuse, non-follicular, pinpoint pustules on a background of erythematous plaques, typically located in intertriginous folds. 1 AGEP is uncommon in the pediatric population and is more likely to be associated with atypical cutaneous features. 2 Drugs are the most common trigger, including penicillins, macrolides, sulfonamides, antifungals, diltiazem, hydroxychloroquine, antiinflammatory medications, and anti-epileptics. 3 In the pediatric population, it is suggested that viral infections may have a greater association with AGEP. 2,4 The traditional clinical course of AGEP in pediatric patients is an acute presentation of the classic eruption with associated high-grade fever and elevated neutrophil counts. 4 Although the clinical picture is concerning, AGEP is typically self-limited, with rapid recovery following cessation of the causative agent and an overall favorable prognosis. 1 Systemic involvement of AGEP with reports of hemodynamic
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