Acute Generalized Exanthematous Pustulosis Simulating Toxic Epidermal Necrolysis

A 25-year-old man was admitted to an intensive care unit and underwent an emergency laparotomy because of widespread abdominal trauma. Tazocin, which is a combination of piperacillin sodium and tazobactam sodium, was administered intravenously as prophylaxis. After 24 hours, the patient developed a widespread eruption consisting of diffuse erythema on his chest, abdomen, and arms along with superimposed nonfollicular pustules (Figure 1) as well as diffuse vesicles and bullae, which coalesced and then sloughed on his back (Figure 2) and legs (Figure 3). A positive Nikolsky sign was present on his back and legs. There was no mucous membrane involvement. The differential diagnosis was thought to be between TEN and AGEP or possibly an overlap of these 2 conditions based on clinical findings. The Tazocin therapy was discontinued after 3 days, and the patient received 1 intravenous immunoglobulin 80-g infusion once a day on 2 consecutive days for suspected TEN, pending the results of his skin biopsies. A skin biopsy specimen was obtained from a pustule and a bulla (Figure 4 and Figure 5), and both specimens were thought to be entirely compatible with AGEP, with no evidence of TEN. Based on the biopsy results, the intravenous immunoglobulin infusions were discontinued, and intravenous hydrocortisone sodium succinate therapy (100 mg every 8 hours for 4 days) was initiated. The pustulation and blistering gradually resolved over 2 weeks, and the patient was left with postinflammatory hyperpigmentation but no scarring.