COVID-19 presenting as acute generalized exanthematous pustulosis associated with multiorgan dysfunction in a 44-year-old female patient

Abstract

Acute generalised exanthematous pustulosis (AGEP) is an unusual cutaneous reaction, most often related with a hypersensitivity reaction to commonly used drugs. It is characterized by an abrupt onset of a pustular rash within hours or days after drug exposure and usually resolves spontaneously within 1-2 weeks after drug discontinuation. Some cases associated with systemic involvement and shock have been reported. We present the case of a severe AGEP, manifesting in association with systemic involvement and haemodynamic instability resulting in shock and multiorgan dysfunction in an adult female patient diagnosed with COVID-19 infection. There were no identifiable associated drugs, and the patient was not initiated on antimalarial drugs. Our patient improved rapidly, both hemodynamically and dermatologically with no directed therapy.

Acute generalized exanthematous pustulosis associated with SARS-CoV-2 infection

“…Acute generalized exanthematous pustulosis is a neutrophilic disease which is related to a type IV immune-mediated hypersensitivity response. After exposure to the causative agent, antigen-presenting cells cause the activation of a specific cluster of differentiation (CD)-CD4 and CD8 T cells, which migrate to the dermis and epidermis, causing apoptosis of keratinocytes, formation of epidermal vesicles, chemotaxis of neutrophils through interleukin 8, and activation and transformation of vesicles into sterile pustules due to a prevalent Th1 and Th17 profile [1][2][3] .…”

“…Histological findings are characterized by intracorneal, subcorneal, or intraepidermal spongiform pustules with papillary dermis edema containing neutrophilic and eosinophilic infiltrates 1 .…”

“…A patch test may be used to identify the cause of AGEP when the causative drug is not clear, but although the sensitivity of these tests in AGEP is around 50%, sensitivity depends on the culprit drug, and there are no reports of positive patch tests to azithromycin or dipyrone in this setting 1,2,4 .…”

“…Acute generalized exanthematous pustulosis is a rare disease characterized by the sudden onset of diffuse sterile pustules on an erythematous background 1,2 .…”

“…It usually improves quickly after discontinuation of the causative agent, even though severe cases have been described. Viral and bacterial agents have also been reported as triggers [1][2][3] , as well as rare additional…”