R. Slim

Hepatotoxicity of alpha‐methyldopa in pregnancy

Alpha‐methyldopa is one of the most widely prescribed antihypertensive agents used during pregnancy. Despite its known potential hepatotoxicity, there have been only a few reports describing hepatotoxicity with the use of this drug during pregnancy. We report here a new case of acute hepatitis in a pregnant woman related to the use of alpha‐methyldopa, and briefly review the literature on alpha‐methyldopa‐induced hepatotoxicity in pregnancy.

Acute generalized exanthematous pustulosis induced by oxacillin confirmed by patch testing

Department of Dermatology, Farhat Hached Hospital, Sousse, Tunisia Department of Pharmacovigilance, Reference Centre for Cutaneous Adverse Reactions, Faculty of Medicine, University of Sousse, Sousse, Tunisia Department of Pathology, Farhat Hached Hospital, Sousse, Tunisia Correspondence Rima Gammoudi, Department of Dermatology, Farhat Hached Hospital, Avenue Ibn Jazzar, 4002 Sousse, Tunisia. Email: rima.gammoudi.fathallah@outlook.fr

Lornoxicam-induced acute generalized exanthematous pustulosis.

pustulosis Editor, Acute generalized exanthematous pustulosis (AGEP) is a severe cutaneous reaction characterized by the sudden onset of small and sterile pustules on erythematous underlying skin. Its diagnosis is more difficult if the patient has a history of psoriasis. Nonsteroidal anti-inflammatory drugs (NSAIDs) have been reported to induce AGEP. However, AGEP with lornoxicam has not been reported previously. Herein, we present the first case of AGEP in a patient with a history of psoriasis. A 39-year-old woman with a 5-year history of psoriasis was treated with acitretin. The patient presented disseminated pustules on the face and trunk. She received lornoxicam for back pain. Two days later, she developed a rapidly extensive erythematous skin eruption without fever. The skin rash extended within 24 hours from the face to involve the skin of the entire body. The patient decided to withdraw the lornoxicam and thus did not use any medication other than acitretin. At the time of admission, physical examination revealed generalized erythroderma patches with pinpoint pustules on the face, trunk, and limbs (Fig. 1). The patient was afebrile and in good general health. Laboratory analyses showed normal leukocytes (8.6 9 10/l) with a 72% (6.2 9 10/l) neutrophil and 3.1% (0.3 9 10/l) eosinophil count. C-reactive protein was normal (<8 mg/l). The results of renal and liver function tests were within normal ranges. There was no evidence of Staphylococcus aureus in the pustules. Viral serologies for human herpesvirus 6, cytomegalovirus, and Epstein– Barr virus (EBV) were negative. Histopathology of a skin biopsy revealed irregular acanthosis, spongiosis, orthokeratosis associated with neutrophil cells, and a large number of non-follicular pustules lying under the corneal layer with rare necrotic keratinocytes (Fig. 2). These histopathological findings were consistent with the diagnosis of AGEP. Based on clinical and histopathological findings, a diagnosis of lornoxicam-induced AGEP was suspected. The patient was treated with acetaminophen for her back pain and topical corticosteroid therapy was started. The outcome was remarkably quick and favorable. The skin eruption resolved within 5 days, followed by postinflammatory desquamation. Furthermore, we did not find any conditions known to represent factors triggering psoriasis, such as stress, skin trauma, medication, or ongoing infection. According to objective causality assessed by the probability scale devised by Naranjo et al., it is probable that the present patient demonstrated AGEP induced by lornoxicam. Moreover, the diagnosis of AGEP was validated as defined by the EuroSCAR study group score. We also excluded AGEP induced by viruses such as parvovirus B19, cytomegalovirus, and EBV, all of which are able to trigger AGEP. In addition to clinical evidence, histology can help in discriminating AGEP from an acute psoriasis episode. We have summarized the most important histological characteristics of the two entities in Table 1. Although AGEP and psoriasis share the characteristic of spongiotic pustules, subcorneal pustules occur more frequently in AGEP than in psoriasis. Necrotic keratinocytes are also found in AGEP but are sporadically observed in psoriasis. Although it is nonspecific to AGEP, dermal edema is relatively frequent, especially at the onset of the condition. Dermal eosinophils are another hallmark of AGEP but are rarely found in psoriasis. By contrast, some histopathological parameters, such as Munro’s microabscess and spongiform macropustules, are Figure 1 Clinical examination shows diffuse erythema with numerous pinpoint pustules on the trunk in a 39-year-old woman