An Acute Generalized Exanthematous Pustulosis Induced by Intravenous Iopromide : A Case Report

Mariem Mohamed1*, Mouna Korbi1, Majed Hassine2, Saber Zerriaa1, Hayet Akkari1, Leila Njim3, Hichem Belhadjali1, Jameleddine Zili1 1Dermatology Department, Fattouma Bourguiba University Hospital, Faculty of Medicine of Monastir, Monastir, Tunisia 2Cardiology Department, Bourguiba University Hospital, Faculty of Medicine of Monastir, Monastir, Tunisia 3Pathology Department, Bourguiba University Hospital, Faculty of Medicine of Monastir, Monastir, Tunisia International Journal of Pharmacovigilance Open Access Case report


Discussion
The diagnosis of AGEP was definite in our patient with a score of 10 referring to the criteria of the Euro SCAR-study [2].In fact, AGEP was first described in 1980 by Beylot, et al. [3].AGEP has been described after the administration of several drugs, including amoxicillin, macrolides, paracetamol and nifedipine [4].Our patient developed AGEP following iopromide which contains iodide.It is a non ionic monomeric contrast medium [5].Iodinated contrast media cause both immediate and non immediate hypersensitivity reactions [5].Non immediate cutaneous hypersensitivity reactions associated with the administration of iodinated contrast media have been described with different clinical presentation [5].These were bullous exanthema, flexural exanthema, purpura/maculopapular eruption combined

Abstract
Acute Generalized Exanthematous Pustulosis (AGEP) is a relatively rare exfoliative dermatosis consisting of a generalized eruption of sterile, nonfollicular pustules arising on widespread erythematous and edematous skin.It is generally attributed to drugs, particularly β-lactam antibiotics, sulfonamide and macrolides.To date, only thirteen cases of contrast media induced AGEP (involving iohexol, iopamidol, iodixanol, and ioversol) have been reported.We describe a patient with AGEP induced by iopromide.He was aged of 49 years.He developed pustular eruption on the back and folds three days after coronarography using radio contrast dye: Iopromide.The culture from pustules was sterile.Laboratory examination revealed an elevated white blood cell count of 22,500/ L with an increased neutrophils count (19,700/ L).A skin biopsy showed the features of an AGEP.The cutaneous eruption resolved with topical corticosteroid within five days.We found only 1 previous reports of iopromideinduced AGEP.

Introduction
Acute Generalized Exanthematous Pustulosis (AGEP) is an uncommon disease.It is characterized by an erythematous pustular eruption and is usually caused by systemic medication especially β-lactam antibiotics, sulfonamide and macrolides [1].We report a case of AGEP induced by iopromide.Iopromideinduced AGEP has been reported previously in only one case through the English literature.

Case report
A 49-year-old man was admitted to cardiology department for an acute coronary syndrome.The patient had a history of coronary heart disease for which an angioplasty was made a year ago.He reported that he was developed a cutaneous rash few days later with spontaneous resolution.He had also a psoriasis vulgaris which was in remission for years.Three days after receiving intravenous iopromide (Ultravist®) for by Intravenous Iopromide: A Case Report.Int J Pharmacovigil 1(2): 4.

An Acute Generalized Exanthematous Pustulosis Induced by Intravenous Iopromide: A Case Report
Copyright: © 2016 Mohamed et al.
with eosinophilia, psoriasis-like exanthema and AGEP [5].Nevertheless, only thirteen cases of contrast media induced AGEP have been described [6,7].Cases reported incriminate iopamidol, ioversol, iohexol and iodixanol [1,[5][6][7][8][9][10][11][12][13][14].Patch tests have confirmed the diagnosis in 3 publications [8,9,11].All cases of contrast media AGEP, including our, are summarized in table 1.Moreover, AGEP induced by iopromide has been previously  described in only one case [8].It was about a 52-year-old woman who developed AGEP three hours after coronary angiography using iopromide (Ultravist®).The rapid onset delay of the AGEP in this woman was explained by advance sensitization as well as our patient [8].In fact, the pathophysiological mechanism of AGEP is not yet clear.Some authors incriminate a type IV allergic reaction [7].So, after drug administration, it may take 1-3 weeks before skin lesions appear [6].However, in previously sensitized patients, the skin symptoms may occur within 24-48 hours [6].On the other hand, the main differential diagnosis in our case was pustular psoriasis.Indeed, the predominance of the eruption in the folds, the rapid resolution of the eruption, the presence of eosinophils in the inflammatory infiltrate and the absence of histological features of conventional psoriasis suggest that our patient had an AGEP.Finally, we report the second case of AGEP induced by iopromide.Our aim is to remain both radiologists and dermatologist aware of this side effect of contrast media.

Table 1 :
Characteristic of radio contrast media acute generalized Exanthematous pustulosis.