Prolonged course of acute generalized exanthematous pustulosis with liver involvement due to sensitization to amoxicillin and paracetamol.

The EuroSCAR group recently assigned paracetamol as “a drug of common use with no significant association” with acute generalized exanthematous pustulosis (AGEP) (1). However, some rare cases of AGEP in association with paracetamol intake have been reported (2–5). We report here the case of a patient for whom we have good evidence (i.e. by skin testing) that AGEP was elicited by a combination of amoxicillin and paracetamol and who showed unusual liver involvement and prolonged course of the disease.CASE REPORTA 48-year-old man with no history of psoriasis was treated with paracetamol because of otitis media. In ad-dition, amoxicillin was started 2 days later and within 3 more days he developed exanthema, which was progres-sive despite immediate cessation of both drugs on day 5 after start of drug therapy, hospital admission on day 6 and therapy with prednisolone-succinate (250 mg/day for 2 days). On day 7 he was referred to our university hospital with pustular suberythrodermic exanthema (Fig. 1a) and oral erosions. Histology from the trunk revealed slight acanthosis and subcorneal pustules filled with neutrophils (Fig. 1b). In the papillary dermis there was a mixed perivascular and interstitial infiltrate of neutrophils, eosinophils and lymphocytes. Skin lesions were accompanied by fever > 39oC, leukocytosis (25/nl), neutrophilia (87%) and increased C-reactive protein level (CRP) (250 mg/l). On day 8, eosinophils and liver enzymes were within normal range, but gamma-gluta-myl transferase (GGT) and alanine aminotransferase (ALT