DR.MOHAMMED IRFAN SHEIKHabout 2 years ago

Acute Generalized Exanthematous Pustulosis

A 60-year-old woman with a history of Sjögren's syndrome, who had begun receiving 200 mg of hydroxychloroquine daily 25 days previously, presented with a 4-day history of generalized erythematous plaques followed by a pruritic, pustular eruption. The patient was febrile, with a temperature of 38.5°C, but hemodynamically stable. Laboratory examination showed a normal white-cell count (9.2×109 per liter) with eosinophilia (eosinophils, 8.8%). The patient said that she had not used any other prescription or over-the-counter medication before the onset of symptoms. Examination revealed widespread edematous erythema covered with numerous discrete, nonfollicular pustules (<5 mm in diameter) coalescing on the palms (Panel A). Yellow hyperplastic papules on the tongue mucosa were also noted (Panel B). Microbiologic studies of the pustules were unrevealing. Histologic findings from skin biopsy showed spongiform intraepidermal pustules and perivascular infiltrates containing neutrophils, lymphocytes, and eosinophils in the upper dermis. These findings are consistent with hydroxychloroquine-induced acute generalized exanthematous pustulosis. Hydroxychloroquine was withdrawn, and prednisolone was given for 2 weeks. The lesions resolved completely over the 2 weeks of prednisolone treatment. No recurrence occurred in the follow-up period of 10 months.