Acute generalized exanthematous pustulosis: a rare side effect of clindamycin.

Introduction: Acute generalized exanthematous pustulosis (AGEP) is a rare adverse effect of clindamycin characterized by widespread papules and pustulosis 1 - 3 weeks of its use. Case description: We present a case of a 71-year-old woman diagnosed with AGEP after clindamycin use for a tooth infection. She had been started on empiric prednisone without benefit. She did not have any systemic involvement and had an unremarkable blood work . Her rash resolved completely in a month.

Clinical description

The patient is a 71-year-old lady seen in primary care physician’s office for non-improvement of diffuse rash that started 2 days prior to completing a 10-day course of clindamycin for a tooth infection. Her rash had been present for 10 days on presentation. She noted erythematous papules and pustules that started on her neck and then quickly spread to her chest and arms over 2 days. They were slightly itchy. She had gone to an urgent care where she was prescribed an 8-day course of prednisone taper. On questioning, she mentioned that she had noted clearing of the rash from the neck region where it had first appeared. She had not noted any mucosal involvement. She did not have any fever or chills. She denied shortness of breath, wheezing or chest tightness. Her past medical history was significant for hypertension and hyperlipidemia. She did not have a known history of psoriasis or any other skin condition. Her home medications included hydrochlorothiazide 12.5 mg daily, meloxicam 15 mg daily, omeprazole 20 mg daily, simvastatin 20 mg nightly, and alprazolam 0.25 mg p.r.n. nightly. None of her home medications were new or had been recently changed and were continued during prednisone use. On examination, her temperature was 98.2 ºF, pulse 96 beats per minute, blood pressure 137/78 mm Hg, and respiratory rate 12 breaths per minute. The patient had a generalized papular rash that coalesced to form plaques on her arms and was studded with non-follicular pustules, along with skin desquamation (Figure 1). Superimposed bacterial skin infection was not noted. She did not have any cervical, axillary or inguinal lymphadenopathy. System examination was unremarkable. Given history of recent clindamycin use and presentation, acute generalized exanthematous pustulosis (AGEP) was suspected. The patient was reassured about the benign nature of the illness and recommended to complete the prednisone taper. She was advised to use fexofenadine as needed for itching. Her complete blood count was within normal range except for an elevated white count of 13.7 10E3/µL (reference range: 4.8–10.8 10E3/µL) with 76.2% (reference range: 37–75%) neutrophils related to prednisone use. Her liver function test was unremarkable. Skin biopsy was not done as it was most likely thought to be related to recent clindamycin use. The patient noted complete resolution of rash in a month on follow up.

Figure 1.

Patient’s right arm demonstrating generalized papular rash, pustules along with skin desquamation.

Teaching points

Clindamycin-associated AGEP should in suspected in patients presenting with erythema followed by papules and pustules within 1 −3 weeks of clindamycin use [1,2].

AGEP is self-limited and treatment involves discontinuation of clindamycin and supportive therapy with corticosteroids, antihistamines or antibiotics [2].