Terbinafine
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Acute generalised exanthematous pustulosis: case report A 63-year-old man developed acute generalised exanthematous pustulosis (AGEP) during antifungal treatment with terbinafine. The man had been receiving antifungal treatment with terbinafine [dosage and route not stated]. Nine days after terbinafine initiation, he presented to the dermatology department with pustular rash on whole body with a profoundly reduced general condition. Subsequent laboratory investigations showed elevated CRP, peripheral blood leucocytosis of and neutrophilia. Histopathologic examination of a skin biopsy showed epidermal spongiosis with apoptotic keratinocytes, intra-epidermal neutrophils with sub-corneal pustules and perivascular lymphocytic infiltrate with numerous neutrophils. Based on the laboratory findings and histopathology report, he was diagnosed with terbinafine-induced AGEP. The man’s terbinafine therapy was discontinued. As a corrective measure, he was treated with prednisone 1 mg/kg/day. However, after 3 days, his symptoms did not improve but rather progressed, indicating lack of efficacy. Due to the history of arterial hypertension and role of interleukin-17 in the pathophysiology of AGEP, he received off-label treatment with secukinumab 300mg (single dose). Within 24 hours of therapy, the symptoms pustules, erythema and skin lesions improved. His treatment with prednisone was discontinued within 3 days, as collarette-shaped desquamation was noticed following resolution of the skin lesions. Thereafter, a long-term follow-up was performed, but no relapse was observed. Histopathologic examination of a skin biopsy showed resolution of epidermal spongiosis and apoptotic keratinocytes with depletion of neutrophils and disappearance of the subcorneal pustules. Enzyme-linked immunospot (ELISpot) analysis revealed increased numbers of terbinafine-specific granzyme Bsecreting T-cells before and shortly after secukinumab treatment. Therefore, it was concluded that, the terbinafine-specific cytotoxic T-cell reaction was responsible for AGEP development. A skin patch test with terbinafine was performed, which showed positive result. Gualtieri B, et al. Interleukin 17 as a therapeutic target of acute generalized exanthematous pustulosis (AGEP). Journal of Allergy and Clinical Immunology: In Practice 8: 803500061 2081-2084e2, No. 6, Jun 2020. Available from: URL: http://doi.org/10.1016/j.jaip.2020.01.045
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Reactions 5 Sep 2020 No. 1820
