A 41-year-old man presented with a 1-day history of rapidly growing erythema and pustules on the face, trunk, and extremities. One day before, he took isoniazid, rifampicin, ethambutol, and pyrazinamide to treat pulmonary tuberculosis in lazaretto. At admission, the patient was febrile to a temperature of 40 C. He also had a 2-year history of plaque psoriasis with no history of smoking. Routine laboratory testing revealed white blood cell count of 13,890/mul (normal range, 1,214-5,110/mul) and serum levels of C-reactive protein (CRP) of 7.75 mg/dl (normal range, 0-0.2 mg/dl). Physical examination revealed widespread erythema and dried-up lakes of pus, taking up body surface area of 80%. Pustules and erythema multiforme-like lesions were diffusely spread over the upper arms and palms (Figures 1a-d). Biopsies of pustule and erythema multiforme-like lesions on the arms were performed. The result demonstrated subcorneal pustules, spongiosis as well as lymphocyte and eosinophils infiltration in the dermis (Figures 1h,i).
The patient was assessed using a diagnostic score according to the EuroSCAR study. The final score was nine, which was defined as the definitive AGEP. The patient was subsequently treated with expectant treatment and topic potent steroids for 4 days, followed by no improvement. However, given the patient's femoral head necrosis, systemic glucocorticoid was not recommended. Repeated computed tomography on the chest showed multiple calcifications and thus excluded the possibility of active tuberculosis. Other infections including hepatitis B and hepatitis C were also excluded. The patient received secukinumab 300 mg after being informed of impersonal medical risks (Supplementary Figure). After the first therapy of secukinumab, all pustules faded at day 3, and erythema substantially darkened with defervescence (Figures 1e-g). The Dermatology life quality index (DLQI) decreased rapidly from 25 to 1 at week 4. There were no clinical symptoms and radiological data related to the progression of latent tuberculosis infection.