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Acute generalized exanthematous pustulosis induced by gliclazide: a case report

Acute generalized exanthematous pustulosis (AGEP) is a rare acute reaction that is drug-induced in 90% of cases and is characterized by the rapid onset of dozens of nonfollicular sterile pustules over an erythematous and edematous skin.1 Moreover, fever, elevated blood neutrophils, and triggering by medications or infections are also observed.2 Pustules resolve spontaneously within a few days. Internal organ involvement is relatively rare, and the mortality rate is approximately 5%. We describe the first case associated with gliclazide. A 78-year-old female was admitted to our unit with a generalized, progressive, erythematous, slightly pruritic eruption of abrupt onset, and her temperature was 38.4 C. The lesions developed three days after starting treatment with gliclazide (Diamicron; Les Laboratoires Servier, Rue Garnier, Neuilly-sur-Seine, Francia) for her diabetes. The medication list included gemfibrozil (Lopid; PFIZER S.R.L., Buenos Aires, Argentina) and enalapril (Acentensil; Laboratorios Andrómaco, Madrid, Spain) for her elevation of cholesterol and hypertension, which she had been taking for over a year. A physical examination revealed numerous discrete and coalescing, brightly erythematous patches on the face, upper extremities, trunk, and thighs, with close-standing small pustules. Purpuric lesions were observed on the

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lower extremities, and the mucosa was not affected. She had no personal or family history of psoriasis. The patient had leukocytosis with elevated neutrophil and eosinophil counts (Fig. 1). High levels of glucose, urea, and creatinine in her blood test were also observed. Other routine laboratory findings were in the normal ranges. Pathological findings revealed spongiform intraepidermal pustules and perivascular infiltrates containing neutrophils, lymphocytes, and eosinophils in the upper dermis. Based on these clinical and histopathological findings (Fig. 2), she was diagnosed with gliclazide-induced AGEP. Upon discontinuation of gliclazide, she developed no new pustules and exhibited generalized superficial desquamation with ultimate resolution within 10 days. In 1968, Baker3 described 104 cases of pustular psoriasis, and in five of these patients, who were without a previous history of psoriasis, the pustular eruption was an acute, short course and did not recur. In 1980, Beylot4 introduced the term ‘‘acute generalized exanthematous pustulosis’’. In 2001 Sidoroff5 proposed the diagnosis criteria for AGEP, and these included: (i) sudden onset of an eruption of numerous, small (

Acute generalized exanthematous pustulosis induced by gliclazide: a case report.

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