LAUSR

Acute generalized exanthematous pustulosis (AGEP) is an acute febrile neutrophilic eruption characterized by fever and extensive sheets of sterile, nonfollicular pustules overlying erythematous, oedematous skin. It is typically caused by drugs but rare cases induced by infection are recognized. Typically, withdrawal of the trigger, followed by supportive care and topical steroids induces rapid resolution. An 83-year-old woman was admitted with abdominal pain. Her medical history included gallstone pancreatitis and cholecystitis, and she had no history of skin disease. Contrast abdominal computed tomography using iopamidol (Niopam 370; Bracco UK Ltd, High Wycombe, Bucks, UK) showed features consistent with acute cholecystitis. The patient was started on intravenous piperacillin/ tazobactam. Within 48 h, she developed an extensive rash, tachycardia, hypotension and pyrexia. Physical examination revealed a widespread confluent erythema of the trunk and limbs, with sparing of the face, extremities and mucosae. Sheets of monomorphic pustules on background erythema were evident on the back, in the groin and in the abdominal folds, with areas of superficial desquamation (Fig. 1). Blood tests demonstrated neutrophilia (30 9 10/L; normal range 2.0–7.5 9 10/L). Histology demonstrated features consistent with AGEP (Fig. 2). Bacterial cultures and viral PCR were negative. Based on the findings, AGEP was suspected. Piperacillin/tazobactam was discontinued as the suspected culprit drug. The patient required intensive care and fluid resuscitation. Regular application of paraffin emollient and clobetasone butyrate 0.05% ointment was initiated. Percutaneous cholecystostomy was performed to drain the gallbladder. The patient’s condition stabilized over 48 h and the rash resolved over the following 5 days. Four weeks later, during her convalescence, the patient developed acute breathlessness. Computed tomography pulmonary angiography with iopamidol demonstrated pulmonary oedema. Within 24 h she developed a pustular eruption that was morphologically identical to the previous one, with fever, hypotension and oliguria. Histology supported the diagnosis of AGEP. Intensive care with inotropic