acute generalized exanthematous pustulosis ( agep ) is a rare acute reaction that is drug - induced in 90% of the cases , characterized by a widespread , sterile pustular rash .
cefepime is a fourth generation cephalosporin antibiotic used to treat febrile neutropenia , severe infections related to the urinary tract , skin , nosocomial pneumonia , brain abscess , and intra - abdominal and septic lateral / cavernous sinus thrombosis .
a 67-year - old man with renal failure who had been on dialysis during the last 2 years and with an 8-year history of cardiac insufficiency was admitted to the hospital complaining of 6 days of diarrhea .
the patient was taken to the semi - intensive care unit and treated with ciprofloxacin . as a consequence ,
his long - term medications had not been changed and consisted of acetylsalicylic acid , furosemide , captopril , carvedilol and clonazepam . on the seventh day , the patient became dyspneic and his chest radiograph showed a left lower lobe opacity .
treatment for nosocomial pneumonia was promptly initiated with cefepime ( 1 g / day ) .
five days later , he presented with a pruritic , erythematous , maculopapular eruption affecting the abdomen , neck and skin folds .
one day later , he developed disseminated pustular lesions ( fig . 1 ) and his temperature was 37c .
laboratory exams evidenced c - reactive protein 136 mg / l , white blood cells 14,700 cells/l ( normal 3,50010,500 cells/l ) with 11,995 cells/l neutrophils ( normal 1,7008,000 cells/l ) .
histology showed a toxic pustuloderma with spongiform subcorneal pustules , edema in the papillary dermis and perivascular inflammatory infiltrate consisting of neutrophils ( fig .
after withdrawal of cefepime and introduction of imipenem , the disseminated skin nonfollicular pustules cleared within 4 days following a desquamation .
the patient denied previous adverse reaction to other drugs and no personal or family history of psoriasis was evident .
agep is a disease characterized by the rapid onset of many sterile , nonfollicular pustules usually arising on an edematous erythema and frequently accompanied by leukocytosis and fever .
skin symptoms usually arise rapidly after an insult and resolve spontaneously ( within a few days ) .
agep often starts predominantly in intertriginous areas or on the face , spreading rapidly to the trunk and lower limbs .
the mean duration of the pustules is 9.7 days , and an annular desquamation typically follows for a few days .
complications are rare [ 1 , 3 ] . the agep validation score of the euroscar study group has been used to establish the diagnosis . a score between 8 and 12 for agep is a definitive diagnosis ( table 1 ) .
the case score was 11 , according to the validation score of the euroscar study group ( table 2 ) .
the main differential diagnosis of agep is pustular psoriasis . because the pustules clinically and histologically resemble the lesions of pustular psoriasis and because in a number of reports patients had a history of plaque psoriasis , some authors assume that agep is nothing more than an acute exacerbation of psoriasis caused by a variety of exogenous triggers
however , many studies strongly suggest that agep is not associated with psoriasis [ 1 , 5 ] . up to now
agep has been attributed to a variety of causes such as viral infections , chlamydia pneumoniae infection   or hypersensitivity to mercury , but the skin reaction is primarily an adverse response to drugs
. antibiotics , other than cefepime , have been implicated as the causative agents in 80% of individuals . in this group ,
the present case of agep has well defined criteria , and because correct diagnosis generally leads to spontaneous resolution once the causative drug is withdrawn , clinicians should keep the possibility of this cutaneous drug reaction in mind .
 acute generalized exanthematous pustulosis ( agep ) is a rare cutaneous rash characterized by widespread sterile nonfollicular pustules . 
 cefepime is a fourth generation cephalosporin , used to treat severe infections . 
 a 67-year - old man was admitted with acute gastroenterocolitis . on the seventh day 
 , the patient developed a nosocomial pneumonia and cefepime was initiated . on the fourth day of cephalosporin treatment , he presented with a maculopapular , pruritic eruption affecting the face , neck , abdomen and limbs . 
 one day later he developed disseminated pustular lesions and his temperature was 37c . 
 laboratory analysis evidenced leukocytosis and skin biopsy showed subcorneal pustule , edema in the papillary dermis , perivascular inflammatory infiltrate consisting of neutrophils , leukocytoclasia and red cell extravasation in the epidermis . 
 cefepime was suspended and within 4 days the non - follicular pustules cleared following a desquamation . 
 agep is a disease attributed to a variety of causes , but in 90% of the cases it is due to an adverse drug reaction . 
 antibiotics are implicated in 80% of these cases , mostly penicillins and macrolides . 
 there are few cases associated with cephalosporins . 
 it is very important to consider agep in cases of acute pustular rashes and drugs should be investigated as causative agents . 
Introduction
Case Report
Discussion