Abstract
Acute generalized exanthematous pustulosis (AGEP) and toxic epidermal necrolysis (TEN) are severe cutaneous adverse reactions that have distinct clinical and pathological features; however, cases with overlapping features have been reported. Differentiation between these conditions is critical because management and prognosis differ. An 82-year-old woman with a history of hepatic cirrhosis and congestive heart failure was admitted to the intensive care unit due to hemorrhagic gastritis complicated by multiorgan failure. Dermatology was consulted for a 24-hour evolution of a mildly erythematous generalized eruption with sloughing of the skin. Seventy-two hours prior, she had been started on intravenous ceftriaxone, vancomycin, and metronidazole. On exam she was afebrile, and had diffuse erythema on the trunk and extremities. Sloughing of the skin was noted primarily on dependent areas and the Nikolsky sign was negative. Her mucous membranes were spared. A complete blood count was notable for leukocytosis. The following day, large blisters filled with clear fluid appeared on non-dependent skin along with scattered pustules on the trunk and extremities. Skin biopsy specimens from the chest and knee demonstrated large, subcorneal collections of neutrophils, interface vacuolar dermatitis, and dense dermal infiltrates of neutrophils, lymphocytes, and eosinophils. Full-thickness epidermal necrosis was noted in some areas. Direct immunofluorescence was negative. The diagnosis of TEN-AGEP overlap was made. The patient was transferred to the burn unit for supportive therapy. Medical management of the cutaneous drug eruption was deferred due to the patients multiple active comorbidities. Her general status worsened due to undifferentiated shock and she expired soon after. Severe AGEP can manifest with overlapping features of TEN. TEN-AGEP overlap is a challenging diagnosis that requires accurate clinic-pathological correlation for the correct management of the patient.
Financial Disclosure:
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