Jiaci

J Investig Allergol Clin Immunol 2019; Vol. 29(5): 403-404

doi: 10.18176/jiaci.0428

LETTERS TO THE EDITOR

Acute Generalized Pustular Bacterid: An Uncommon

Dermatosis That Commonly Presents With Acral

Pustules

Zhou HW, Tan C

Department of Dermatology, Affiliated Hospital of Nanjing

University of Chinese Medicine, Nanjing, China

J Investig Allergol Clin Immunol 2019; Vol. 29(5): 403-404

doi: 10.18176/jiaci.0428

Key words:

Allergy. Dermatology. Pustules.

Palabras clave:

Alergia. Dermatología. Pústulas.

To the Editor:

We read with great interest the very well-presented article

entitled “Acute Localized Exanthematous Pustulosis Due to

Bemiparin” by Gómez Torrijos et al [1]. The authors reported

the case of a patient with pustular eruptions on the palms,

which were finally diagnosed as a localized subtype of acute

generalized exanthematous pustulosis (AGEP). We recently

saw a similar case with acral pustular eruptions, in which

the diagnosis of acute generalized pustular bacterid (AGPB)

was established based on the triad of acral distribution of the

pustules, sudden onset of the disease, and concomitant remote

localized bacterial infections.

A 42-year-old man had a 2-day history of pustular

eruption on both hands that had developed suddenly. Several

days earlier, he had had a sore throat with fever of 38.5°C.

He denied having taken drugs and had no history of drug

allergy, including to cefuroxime. Similarly, he had no history

of psoriasis. Physical examination showed many isolated,

discrete pustules on both hands (Figure). The results of routine

testing of blood (6.2×10

/L), urine, and stool and a basic

biochemistry panel (ALT, 34 μ/L; AST, 26 μ/L) were normal.

Laboratory results revealed C-reactive protein of 53 mg/dL

and an erythrocyte sedimentation rate of 35 mm/h. Bacterial

culture from a throat swab demonstrated multiple group A

ß-hemolytic streptococci. Repeated cultures of pus for bacteria

and fungus were negative. Skin biopsy of a pustule showed

subcorneal spongiform accumulation of neutrophils, slight

dermal edema, and perivascular in ltration (Supplementary

Figure). No evidence of leukocytoclastic vasculitis was

found. The patient was diagnosed with AGPB. Intravenous

cefuroxime was administered at a single dose of 1.5 g twice

daily for 7 days. The pustules cleared, with gradual resolution

of the sore throat. No pustules were observed during the 1-year

follow-up.

Skin manifestations of infections in other organs and

tissues are diverse and are often the first observed signs of

a disease. AGPB was first described by Andrews et al [2] in

1935. It has also been called pustular bacterid or pustulosis

acuta generalisata [3], which is characterized by the presence

of acral pustulosis, mostly with a focal infection [4].

AGPB manifests as sterile, isolated, small pustules with

an erythematous halo. The rash is neither edematous nor

scaly, and the diameter of the pustules has a range of several

millimeters.AGPBmainly affects the palms and the soles, and,

to a lesser extent, other parts of the limbs [4]. Occasionally,

AGPB is generalized. There is usually intermittent fever, and a

few cases present rare complications (eg, glomerulonephritis,

arthralgia, and ankylosing spondylitis) as the disease

progresses. AGPB sometimes co-occurs with Tietze syndrome

and sternocostoclavicular hyperostosis. Most pustules resolve

within 12 days after onset. Skin specimens in AGPB show

subcorneal spongiform accumulation of neutrophils and

perivascular in ltration. Leukocytoclastic vasculitis and

neutrophilic panniculitis can sometimes be observed [4].

The features that point us to the correct diagnosis ofAGPB

include absence of psoriasis or other skin conditions, focal

Figure.

Multiple isolated discrete pustules surrounded by a narrow rim of

erythema. The pustules vary in size from 2 to 6 mm in diameter and are

distributed on both hands and, to a lesser extent, the forearms.