An illusion of septic shock: acute generalised exanthematous pustulosis with multiorgan dysfunction

Abstract

Acute generalised exanthematous pustulosis (AGEP) is a rare cutaneous eruption, most often caused by commonly used antibiotics. It is characterised by an acute onset of non-follicular sterile pustular rash and erythema within hours or days of drug exposure and usually resolves spontaneously within 1–2 weeks once the drug is discontinued. Haemodynamic involvement in the form of shock is rare. Here, we present a severe case of AGEP, manifesting with systemic involvement and haemodynamic instability resulting in shock with multiorgan dysfunction. The associated drugs were erythromycin and fluconazole with a possible combined effect of these two drugs that resulted in systemic involvement. Our patient improved markedly, both haemodynamically and dermatologically, after discontinuation of the drugs and with systemic steroid therapy.

Multisystem organ failure secondary to acute generalised exanthematous pustulosis (AGEP) with atypical presentation resembling septic shock

“…In the case described, our patient required intensive care treatment, vasopressor support and use of systemic corticosteroids. 6 18 20 …”

“…5 Rarely, AGEP cases may present with mild hepatic and kidney injury. [6][7][8] AGEP is a type intravenous hypersensitivity reaction caused most commonly by antibiotics, although other drug classes, viral infections and unknown triggers have been reported. 9 Onset of skin manifestation is highly variable, with clinical signs observed in less than 48 hours 8 or up to weeks.…”

Clinical characteristics and management of acute generalized exanthematous pustulosis with haemodynamic instability

“…5 However, only 15 adult cases of AGEP with haemodynamic instability have been reported in the literature. [9][10][11][12][13][14][15][16][17][18][19][20][21][22][23] The pathophysiology of AGEP is a drug-specific CD4+ and CD8+ T cell response that results in increased production of IL-8, a potent neutrophilattracting chemokine. 25 Other inflammatory cytokines, including IL-17 and IL-22, also have a role in the pathophysiology of AGEP, and may be involved in the systemic complications of AGEP.…”

Macrolide Allergic Reactions

“…The breakdown of studies included 88 case reports, 12 case series, 2 cross-sectional, 1 double-blind, placebo-controlled, 5 prospective, and 12 retrospective. There were 58 publications describing erythromycin-associated allergic reactions [19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34,35,36,37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,60,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77]. There were 33 publications describing clarithromycin as a culprit for allergic reactions [72,73,75,78,79,…”

“…Erythromycin (n = 1), clarithromycin (n = 2), and azithromycin (n = 1) have been implicated in leukocytoclastic vasculitis [60,79,84,113]. Fourteen publications implicated a macrolide as the cause of an allergic reaction with subjects who received concomitant antimicrobials [25,41,44,45,46,58,76,78,90,101,102,105,119,131]. The most common concomitant agents were an aminoglycoside (n = 3), a beta-lactam (n = 3), and a sulfa (n = 4) [41,44,45,46,78,90,101,102,119,131].…”