10.5826/dpc.1202a58
text/xml
2160-9381
1840
en
Lobna Boussofara
https://creativecommons.org/licenses/by-nc/4.0
Dermatology Practical & Conceptual
patch test
Recurrent acute generalized exanthematous pustulosis to two different drugs: Oxacillin and Dextromethorphan confirmed by patch test
Text.Serial.Journal
https://dpcj.org/index.php/dpc
Research Letter
2022-05-02
2021-06-13
2022-05-02
2022-05-24
e2022058
Dermatol Pract Concept
Lobna Boussofara
2022/05/02
10.5826/dpc.1202a58
e2022058
Department of Dermatology, Farhat Hached hospital, Sousse, Tunisia
2160-9381
patch test
en
e2022058
Rashid, RS, Ahmed, I, Shim, TN. Acute generalized exanthematous pustulosis due to dextromethorphan. Contact Dermatitis. 2020;83(5):424– 425. DOI: 10.1111/cod.13633. PMID: 32506524.
Recurrent acute generalized exanthematous pustulosis to two different drugs: Oxacillin and Dextromethorphan confirmed by patch test
https://dpcj.org/index.php/dpc/article/download/1840/1567
      Recurrent Acute Generalized Exanthematous
     Pustulosis to Two Different Drugs: Oxacillin and
       Dextromethorphan Confirmed by Patch Test
                Zied Kenani1, Rima Gammoudi1, Neila Fathallah2, Amina Aounallah1,
              Sana Mokni1, Lobna Boussofara1, Nejet Ghariani1, Colandane Belajouza1,
                              Chaker Ben Salem2, Mohamed Denguezli1


1 Department of Dermatology, Farhat Hached hospital, Sousse, Tunisia
2 Department of pharmacovigilance, Reference center for cutaneous adverse reactions, Faculty of medicine, University of Sousse,
  Sousse, Tunisia.



Key words: Acute generalized exanthematous pustulosis, oxacillin, dextromethorphan, recurrence, patch test
Citation: Kenani Z, Gammoudi R, Fathallah N et al. Recurrent Acute Generalized Exanthematous Pustulosis to Two Different Drugs:
Oxacillin and Dextromethorphan Confirmed by Patch Test. Dermatol Pract Concept. 2022;12(2):e2022058.
DOI: https://doi.org/10.5826/dpc.1202a58
Accepted: August 24, 2021; Published: April 2022
Copyright: ©2022 Kenani et al. This is an open-access article distributed under the terms of the Creative Commons Attribution-
NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use,
distribution, and reproduction in any medium, provided the original authors and source are credited.
Funding: None.
Competing interests: None.
Authorship: All authors have contributed significantly to this publication
Corresponding author: Zied Kenani, MD, Department of Dermatology, Farhat Hached Hospital, Avenue Ibn Jazzar, 4002, Sousse, Tunisia.
E-mail: zieedken@gmail.com




Introduction                                                            which had started 2 days after the intake of oxacillin and
                                                                        tiaprofenic acid. Investigations found an elevated absolute
Acute generalized exanthematous pustulosis (AGEP) is a                  neutrophil count and skin biopsy demonstrated histologic
potentially severe skin condition, mainly drug induced [1].             features consistent with AGEP. Skin lesions totally resolved
Recurrences are rare and generally induced by related drugs.            within 10 days after oxacillin discontinuation. A patch test
Dextromethorphan is an antitussive agent which is unusu-                with oxacillin and tiaprofenic acid (the commercialized form
ally reported as culprit in AGEP. Herein we report a rare case          used by the patient diluted to 30% pet.) was performed and
of relapsing AGEP to dextromethorphan and oxacillin.                    showed a +++ skin reaction to oxacillin on day 4 but no
                                                                        reaction to tiaprofenic acid. All penicillins were prohibited.
                                                                             Two years later the patient presented with a similar
Case Presentation
                                                                        eruption and fever 4 days after taking 2 multi-compound
A 32-year-old woman, with a history of a controlled gener-              medications named goldix day (dextromethorphan, doxyl-
alized pustular psoriasis, presented to our department with a           amine, paracetamol) and goldix night (dextromethorphan,
4 day history of fever with predominately flexural eruption             paracetamol, phenylephrine) for a cold (Figure 1). She de-
of non-follicular pustules on a erythematous background,                nied taking any other drug. Complete blood count showed



Research Letter | Dermatol Pract Concept. 2022;12(2):e2022058                                                                        1
                                                                         paracetamol. We performed a genetic analysis to determine
                                                                         whether there was mutation of the IL36RN gene, as it may
                                                                         be a predisposing factor, but we did not find such mutation
                                                                         in our patient.


                                                                         Conclusions
                                                                         Recurrences in AGEP are rare and often induced by related
                                                                         drugs, mainly B-lactams. Our case suggests that it may be
                                                                         induced by chemically different medications in potentially
                                                                         predisposed patients possibly having pattern of cytokine dys-
                                                                         regulation. Indeed, it seems that psoriasis might be a risk
                                                                         factor of relapsing AGEP. We have also shown that IL36RN
Figure 1. Diffuse erythema with multiple small pustules.                 gene mutation does not fully explain the pathogenesis of
                                                                         pustular generalized eruptions. Moreover, our observation is
                                                                         notable for the implication of dextromethorphan, a widely
                                                                         used opioid antitussive agent, as a culprit drug. To the best
marked neutrophilia and skin biopsy was consistent with                  of our knowledge, only 1 case of AGEP induced by dextro-
AGEP. Diagnosis was defined following EuroSCAR criteria.                 methorphan and confirmed by patch testing has been previ-
Patch testing with the component of the commercialized                   ously reported [2].
package of goldix day (30 % pet.), goldix night (30 % pet.)
and paracetamol (50% pet.) was performed. The patch test
preparations were applied in IQ Ultra (Chemotechnique
                                                                         References
­Diagnostics). The patch tests were occluded for 48 hours, and            1. Sidoroff A, Dunant A, Viboud C, et al. Risk factors for
readings were performed according to ICDRG/ESCD criteria                     acute generalized exanthematous pustulosis (AGEP)—re-
on day 2 and day 4. Patch testing showed a ++ skin reaction                  sults of a multinational case-control study (EuroSCAR). Br
                                                                             J Dermatol. 2007;157(5):989–996. DOI: 10.1111/j.1365-
to goldix day and goldix night, but was negative to parac-
                                                                             2133.2007.08156.x. PMID: 17854366.
etamol (Figure 2). The oral provocation test to paracetamol
                                                                          2. Rashid, RS, Ahmed, I, Shim, TN. Acute generalized exanthem-
was also negative. The constituent dextromethorphan was                      atous pustulosis due to dextromethorphan. Contact Derma-
not available for testing, but was suspected as the cause of                 titis. 2020;83(5):424–425. DOI: 10.1111/cod.13633. PMID:
the reaction as it was the only compound in common besides                   32506524.




Figure 2. (A) Positive patch test reaction to goldix day on day 4. (B) Positive patch test reaction to goldix night on day 4. (C) No reactions
to paracetamol were seen on day 4.




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