a 61-year - old woman came to our attention and was hospitalized for the acute onset of fever ( 38c ) , erythroderma , and pustulosis ; the pustules were mainly localized on her shoulders , upper arms , and trunk [ figure 1 ] . in the latter area
clinical history revealed that she had been treating a bacterial inguinal intertrigo for 4 days with ciprofloxacin 500 mg tablets twice daily and desloratadine 5 mg tablet once daily .
she referred that she had already taken ciprofloxacin in the past for refractory urinary tract infections .
laboratory tests showed leukocytosis ( 23,000/ml , nv 390011700 ) , neutrophilia ( 86.4% , nv 39.674.7 ) , increased c - reactive protein ( 188 mg / l , nv < 8) , increased fibrinogen ( 505 mg / l , nv 200400 ) , increased d - dimers ( 4.8 mg / l , nv < 0.5 ) , slightly increased urea ( 41 mg / dl , nv 1538 ) , and decreased glomerular filtration rate ( 66 ml / min , nv > 90 ) .
skin biopsy showed a nonfollicular , subcorneal , neutrophilic pustule with eosinophils , histiocytes , mild spongiosis , and moderate papillary dermal edema .
erythroderma and pustulosis of our patient at the first day of hospitalization the cutaneous morphology , course , histological findings , and laboratory examinations were consistent with a definite diagnosis of agep according to the validation score of the euroscar study group ; we therefore reported it to italian pharmacovigilance .
we immediately stopped the ciprofloxacin and started infusional therapy with methylprednisolone 40 mg once daily and trimeton ( chlorphenamine ) 10 mg twice daily .
the rash significantly improved within a few days ; after complete resolution of the lesions , patch tests and lymphocyte proliferation test performed with ciprofloxacin both resulted negative .
the most important step of agep diagnosis is to identify the provocative agent : if it is a drug , it must be discontinued immediately , if an infection , immediately treated .
commonly , agep is caused by penicillins and cephalosporins , sometimes by fluoroquinolones ( especially norfloxacin and ofloxacin ) . to the best of our knowledge ,
this is the third reported case of agep caused by ciprofloxacin , supporting two other previous reports . in 2005 ,
knoell and lynch reported the case of a 63-year - old man with a photoinduced acute exanthematous pustulosis ( an unusual form of agep ) caused by ciprofloxacin and exposure to ultraviolet light .
diagnosis was made on the basis of clinical and histological findings . in the same year , hausermann et al . reported another case of ciprofloxacin - induced agep in an 80-year - old woman who also showed a positive patch test to the drug .
patch testing with the drugs involved is a useful and noninvasive way to identify the culprit agent of agep but is characterized by low sensitivity , being positive in about 60% of cases .
the lymphocyte proliferation test seems promising but likewise has low sensitivity . as in our case ,
a negative reaction to these tests should not prompt a reconsideration of the diagnosis that remains primarily clinical .
 acute generalized exanthematous pustulosis ( agep ) is an uncommon and self - limiting skin rash commonly caused by drugs and is characterized by the acute onset of fever , pustulosis , and neutrophilia from 4 to 10 days after the drug intake . 
 we describe a case of agep in a 61-year - old woman that was hospitalized for the acute onset of fever , erythroderma , and pustulosis . 
 clinical history revealed that she had been treating a bacterial inguinal intertrigo for 4 days with ciprofloxacin 500 mg tablets twice daily and desloratadine 5 mg tablet once daily . to the best of our knowledge , 
 this is the third reported case of agep caused by ciprofloxacin , supporting two other previous reports . 
Case Report
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