Cristina Rubio Flores

Acute localized exanthematous pustulosis secondary to levofloxacin

SIR, Acute generalized exanthematous pustulosis is a recently described clinical entity. In 1991 Roujeau et al. described 63 cases of acute and generalized nonfollicular pustules associated with fever. Most of these patients had received drugs (mainly antibiotics); the rash developed within a period of 48 h, and was accompanied by pyrexia (more than 38 C). The disease was self-limiting, and resolved with desquamation within 2 weeks, after the drug was withdrawn. Since the first description, the list of drugs involved has been increasing, but this is the first report showing a relationship between levofloxacin and the disorder. Moreover, acute generalized exanthematous pustulosis is characterized by hundreds of confluent pustules that appear on the face and trunk or in a generalized distribution, and a localized presentation has not been described previously. We report a 70-year-old man who reported a mesencephalic infarction 6 months previously and was receiving treatment with aspirin and the antidepressant paroxetine. He was hospitalized due to pneumonia, and treatment with levofloxacin 500 mg twice daily was immediately instituted. Two days later multiple nonfollicular pin head-sized pustules on an erythematous background appeared over the head and neck (Fig. 1). On day 4, levofloxacin was replaced by clindamycin and piperacillin because the patient had failed to improve. From this moment the cutaneous lesions improved, but when levofloxacin was reintroduced because of intolerance to piperacillin (diarrhoea), these worsened within less than 24 h: the lesions converged and purulent lakes could be seen on the forehead, with a symmetrical distribution, but lesions did not extend to the rest of the body. The patient’s general status worsened (reappearance of fever up to 39 C). The white cell count was 28 · 10 L, with a normal differential. Other routine laboratory parameters, including kidney and liver function tests, were normal. The clinical diagnosis was acute localized exanthematous pustulosis, which was confirmed by means of sterile cultures of pustules and characteristic skin biopsy showing subcorneal pustules with mild spongiform pustulation at the margins, scattered apoptotic keratinocytes and exocytosis of neutrophils adjacent to the pustules; the papillary dermis was oedematous and with a prominent mixed inflammatory cell infiltrate in the upper dermis, with numerous eosinophils. Seven days later, after levofloxacin was withdrawn, most lesions had disappeared, with the remainder persisting as small haemorrhagic crusts (Fig. 2). There are numerous entities involved in this condition, such as viral infections and ultraviolet radiation, but drugs are the main causal agents. Among these drugs are antifungals, calcium antagonists, antiulcer drugs (e.g. famotidine and lansoprazole), corticosteroids and, most frequently, antibiotics. In the series of Roujeau et al., 87% of the cases were due to drugs, 80% of them to antibiotics. To our knowledge, our case is the first described due to levofloxacin. It also has the peculiarity that the lesions were localized.