Acute generalized exanthematous pustulosis following oral treatment with moxifloxacine

ARTICLE

Auteur(s) : Robert Feldmann, Michael Schierl, Paul G Sator, Friedrich Breier, Andreas Steiner

Department of Dermatology and Venerology, Hospital Hietzing, Wolkersbergenstr.1, 1130 Vienna, Austria

Acute generalized exanthematous pustulosis (AGEP) is a rare cutaneous reaction, usually caused by a wide range of drugs, the most important of which are antibiotics [1]. Occasional cases of AGEP have been attributed to infections with chlamydia pneumoniae, enteroviruses and parvovirus B19 [2]. We report the first case of AGEP following the intake of moxifloxacine.

A 76-year-old female was admitted to our department with a generalized erythematous rash evolving rapidly into a pustular eruption (figure 1A). We observed no mucous membrane lesions. The patient had fever (37.8 °C), blood analysis revealed leucocytosis (20.2 G/L), eosinophilia (8%) and neutrophilia (79%) but no other pathological findings. With the exception of moxifloxacine, a quinolone, which had been taken for upper respiratory tract infection one week prior to admission, no other new drug had been applied. The occurrence of psoriasis in the patient’s and family’s history was denied.

DRESS syndrome (drug reaction with eosinophilia and systemic symptoms) was ruled out by the absence of lymphadenopathy, hepatopathy or other signs of visceral involvement. Repeated serological screening for viral infections remained negative. Swabs from pustular lesions for pathogenic bacteria or fungi showed no pathological results. Histopathological examination revealed subcorneal pustules containing neutrophil granulocytes, slight acanthosis and spongiosis (figure 1B). The upper dermis presented interstitial edema and perivascular infiltration with neutrophils and eosinophils.

In the light of our patient’s history, symptoms and clinical presentation we diagnosed AGEP following the intake of moxifloxacine. After discontinuation of the antibiotic and intravenous administration of corticosteroids (100 mg prednisolone daily) and antihistaminics (30 mg diphenhydramine hydrochloride twice a day), the rash cleared with typical generalized desquamation within one week. A consecutive patch test with moxifloxacine remained negative. A provocation test with the drug was not performed.

Recent reports suggest an association between the administration of moxifloxacine and elevated liver enzymes, potentially ending in hepatitis fulminans and Stevens-Johnson-Syndrome or TEN (toxic epidermal necrolysis). In this regard our patient remained without relevant pathological findings. AGEP is usually caused by a large variety of drugs, including antibiotics (ß-lactams, pristinamycine, co-trimoxazole, metronidazole), antifungal agents (nystatin, terbinafine, fluconazole, amphotericin B), carbamazepine, hydroxy-chloroquine, azathioprine, diltiazem, nimesulide, non-ionic contrast media and others [1, 3]. Occasional cases of acute pustular drug reactions after the intake of other quinolone antibacterial agents have already been reported [4-6]. Our case is the first description in the literature of AGEP after treatment with moxifloxacine.

Acknowledgments

References

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