Acute generalized exanthematous pustulosis caused by an iodinated contrast radiocontrast medium for computed tomography arthrography of the knee

Velter, C.; Schissler, C.; Moulinas, Chloé; Tebacher-Alt, Martine; Siedel, Jean-Marie; Cribier, B.; Lipsker, Dan

doi:10.1111/cod.12724

Cited by 15 publications

(18 citation statements)

References 17 publications

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“…The following ICM agents have been reported to induce AGEP: iohexol, iopamidol, iodixanol, ioversol, iobitridol, iopromide, and iomeprol. 4 Eight of 16 reported cases were patch tested, and seven had positive reactions. 4 This is a high proportion as compared with other delayed reactions induced by ICM.…”

Section: Discussionmentioning

confidence: 99%

“…4 Eight of 16 reported cases were patch tested, and seven had positive reactions. 4 This is a high proportion as compared with other delayed reactions induced by ICM. 8 Multiple cross-reactivity, as seen in our patient and in other series, 6,9,10 is challenging.…”

Section: Discussionmentioning

confidence: 99%

“…12 The use of different classes of contrast agents lacks consensus, 1 but monomeric agents with low osmolarity should probably be preferred. 4 Moreover, the intensity of the patch test reaction cannot predict the severity of a new episode of AGEP. Therefore, we anticipated a new occurrence of AGEP after coronarography with iopromide, so we administered a 5-day course of oral prednisone.…”

Section: Discussionmentioning

confidence: 99%

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Acute generalized exanthematous pustulosis induced by iomeprol with cross‐reactivity to other iodinated contrast agents and mild reactions after rechallenge with iopromide and oral corticosteroid premedication

et al. 2019

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K E Y W O R D S : acute generalized exanthematous pustulosis, case report, cross-reactivity, delayed adverse drug reactions, iodinated contrast media reactions, iomeprol Hypersensitivity reactions to iodinated contrast media (ICM) are rare and occur within 1 hour after infusion, but also up to 7 days later. 1 Delayed reactions may be under-reported, because they may appear after patient discharge. 2 Reactions are usually mild to moderate, but more severe cases, including generalized acute generalized exanthematous pustulosis (AGEP), have been reported. 3,4 Patch testing helps in identifying the culprit drug in AGEP, 5 and may help in choosing an alternative therapy when a new radiological examination involving ICM infusion is required. 6 CASE REPORTAn 88-year-old patient underwent three radiological examinations requiring intravenous infusion of iomeprol within a few days for preoperative assessment of aortic stenosis and ischaemic heart disease. Prior medication included furosemide, paracetamol, and simvastatin, all of which were taken for >1 year. At 24 hours after the third injection, the patient was admitted for acute exanthema, with a temperature of 39.9 C ( Figure 1A). Numerous pustules were present on the face (Figure 1B), axillary folds, and trunk. Blood tests showed leukocytosis, at 21 g/L, with polymorphonuclear cells at 19 g/L. A skin biopsy showed an intraepidermal pustule with numerous polymorphonuclear cells.Patch testing was performed 6 months after the occurrence of AGEP. Tests with ioxitalamate (++), iohexol (+++), iomeprol (+++), iobitridol (++), iopamidol (++), ioversol (+++), iodixanol (+++) and iopromide (+) gave positive reactions. A test with amidotrizoate gave a 74MACHET ET AL.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Acute generalized exanthematous pustulosis induced by iomeprol with cross‐reactivity to other iodinated contrast agents and mild reactions after rechallenge with iopromide and oral corticosteroid premedication

et al. 2019

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“…Latency of onset was between 2 h and 3 days after ICM, with almost half of the cases (7/16) being triggered by iodixanol. The authors identified a higher rate of AGEP with dimeric iso‐osmolar CM compared with monomeric low osmolality CM …”

Section: Reactions To Iodinated Contrast Mediamentioning

confidence: 99%

Contrast media and cutaneous reactions. Part 2: Delayed hypersensitivity reactions to iodinated contrast media

et al. 2019

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Contrast media (CM) are an indispensable part of modern medical imaging. Adverse reactions to CM are uncommon, but frequently involve cutaneous symptoms. This two-part article reviews adverse events secondary to CM that are relevant to the practising dermatologist. Part 1 covers the classification of CM, immediate hypersensitivity reactions to CM and the newly described condition, gadolinium deposition disease. Given that there has only been two case reports to our knowledge of a delayed adverse reaction to gadolinium-based CM, this second part will focus on cutaneous delayed reactions caused by iodinated CM (ICM). Delayed hypersensitivity reactions to ICM commonly present as maculopapular exanthems, but more rarely, they can manifest as fixed drug eruptions, acute generalized exanthematous pustulosis, drug-related eosinophilia and systemic symptoms, Stevens-Johnson syndrome/ toxic epidermal necrolysis, symmetrical drug-related intertriginous and flexural exanthema, graft-versus-host disease, vasculitis and iododerma. Delayed reactions to ICM may be underdiagnosed, as cutaneous symptoms may be attributed to oral medications, particularly if patients are on multiple drugs.

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“…The vast majority of AGEP cases are caused by drugs, particularly aminopenicillins, macrolides and quinolones. AGEP triggered by intravenous contrast agents is rare, with only 16 reported cases in the literature and only 1 previously reported case of iopamidol as the causative agent . Recessive mutations in the IL36RN gene, which encodes the anti‐inflammatory interleukin (IL)‐36 receptor antagonist, may underlie some forms of AGEP as well as generalized pustular psoriasis, which can present with a clinically similar picture …”

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confidence: 99%

Accidental re‐exposure causing repeated severe acute generalized exanthematous pustulosis

2019

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Acute generalized exanthematous pustulosis (AGEP) is an acute febrile neutrophilic eruption characterized by fever and extensive sheets of sterile, nonfollicular pustules overlying erythematous, oedematous skin. It is typically caused by drugs but rare cases induced by infection are recognized. Typically, withdrawal of the trigger, followed by supportive care and topical steroids induces rapid resolution.An 83-year-old woman was admitted with abdominal pain. Her medical history included gallstone pancreatitis and cholecystitis, and she had no history of skin disease. Contrast abdominal computed tomography using iopamidol (Niopam 370 TM ; Bracco UK Ltd, High Wycombe, Bucks, UK) showed features consistent with acute cholecystitis.The patient was started on intravenous piperacillin/ tazobactam. Within 48 h, she developed an extensive rash, tachycardia, hypotension and pyrexia.Physical examination revealed a widespread confluent erythema of the trunk and limbs, with sparing of the face, extremities and mucosae. Sheets of monomorphic pustules on background erythema were evident on the back, in the groin and in the abdominal folds, with areas of superficial desquamation (Fig. 1). Blood tests demonstrated neutrophilia (30 9 10 9 /L; normal range 2.0-7.5 9 10 9 /L).Histology demonstrated features consistent with AGEP (Fig. 2). Bacterial cultures and viral PCR were negative.

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Acute generalized exanthematous pustulosis caused by an iodinated contrast radiocontrast medium for computed tomography arthrography of the knee

Cited by 15 publications

References 17 publications

Acute generalized exanthematous pustulosis induced by iomeprol with cross‐reactivity to other iodinated contrast agents and mild reactions after rechallenge with iopromide and oral corticosteroid premedication

Acute generalized exanthematous pustulosis induced by iomeprol with cross‐reactivity to other iodinated contrast agents and mild reactions after rechallenge with iopromide and oral corticosteroid premedication

Contrast media and cutaneous reactions. Part 2: Delayed hypersensitivity reactions to iodinated contrast media

Accidental re‐exposure causing repeated severe acute generalized exanthematous pustulosis

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