Acute Generalized Exanthematous Pustulosis after Ingestion of Lacquer Chicken: DISCUSSION
AGEP is an acute pustular eruption characterized by numerous, non-follicular pustules arising on a widespread erythematous base, which usually ap-pears first in the intertriginous areas and then spreads to other body sites. Neutrophilia and high fever are also usually present. The pustules resolve spontaneously within a few days and are followed by pinpoint desquamation. Histologically, AGEP is characterized by spongiform intraepidermal or sub- corneal pustules, dermal edema, vasculitis, periva- scular neutrophils or eosinophils, and necrotic kera- tinocytes.
AGEP is induced by systemic drugs in over 90% of cases, mainly в-lactam and macrolide anti-microbials. Calcium channel blockers, anti-malarials, and terbinafine have also been reported to cause AGEP. In addition, viral infections, mercury ex¬posure, Ginkgo biloba, and spider bites may serve as occasional causes.
Lacquer chicken contains a known contact al-lergen, urushiol, the active component of which is pentadecylcatechol (PDC). When a previously sen-sitized person ingests the food, urushiol can reach the skin through the circulation and can cause systemic contact dermatitis. Common skin mani-festations include maculopapular eruption, erythema multiforme, and erythroderma. Purpura, wheals, and blisters have occasionally been reported. AGEP very rarely occurs secondary to ingestion of lacquer chicken. To date, four cases have been reported by Park et al. All the patients in their report developed AGEP within one to four days after ingestion of lacquer chicken, and with or without treatment, all the eruptions resolved within ten days.
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The mechanism responsible for the induction of AGEP after lacquer chicken ingestion is unknown. Girardi et al demonstrated drug-specific positive patch test responses and in vitro lymphocyte proli-ferative responses in patients with a history of AGEP, a finding that strongly suggests that AGEP occurs via an antigen-specific T-cell-mediated pro-cess. Similar mechanisms may have triggered the appearance of AGEP in our patient. Although we did not challenge him with a patch test, it is possible that ingestion of lacquer chicken induced AGEP in our patient because there is a causal relationship between intake of the food and the skin eruption. There were no other possible causes in our patient.
AGEP should be differentiated from other pustular dermatoses, such as generalized pustular psoriasis and subcorneal pustular dermatosis. Pustular psoriasis also demonstrates similar pustules, but it is usually associated with papillomatosis and acanthosis. Clinically, most patients with pustular psoriasis have a past history of psoriasis and show more generalized, longer lasting eruptions than those with AGEP. Subcorneal pustular dermatosis tends to affect mainly intertriginous areas, and each lesion spreads peripherally and leaves a central polycyclic area. Histologically, spongiosis and leukocytoclastic vas- culitis are less commonly seen in subcorneal pustular dermatosis.
The most important aspect of AGEP treatment is the immediate withdrawal of the causative agent. Because of the self-limited nature of AGEP, other specific treatments are not usually needed, but topical or systemic corticosteroids can be helpful.
To our knowledge, lacquer chicken-induced AGEP is a rare entity. Our case adds lacquer chicken to the list of etiologies for AGEP and reinforces the idea that lacquer chicken should be avoided be¬cause of its severe cutaneous and systemic effects.