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cutaneous adverse drug reactions are estimated to be about 30% of all adverse drug reactions and observed in 2 - 3% of hospitalized patients .
acute generalized exanthematous pustulosis ( agep ) is a generalized pustular eruption that is primarily drug - induced in probably more than 90% of case . in a few cases infections including cytomegalovirus and parvovirus b19 ,
a spider bite was recently implicated as a possible cause of agep in three patients .
although various drugs have been implicated in this condition , there are no reported cases of agep caused by oral oxicams in the current literature .
this was a case report of a 61-year - old female patient who was admitted to internal medicine department for renal colic .
the patient had a history of longstanding arterial hypertension for 3 years treated with captopril , indapamide , nifedipine and diabetes mellitus for 3 years treated with glibenclamide , glimepiride and dyslipidemia treated with simvastatin .
she was given oral piroxicam 20 mg / day by her primary care physician for treatment of renal colic .
there were no other medications prior to starting piroxicam . at 4 days after starting oral piroxicam , she developed a generalized itchy eruption consisting of multiple papules that sometimes coalesced to larger and scaly plaques , on a background of widespread erythema with associated multiple 2 - 3 mm pustules [ figure 1 ] .
her white blood cell count was 10.8  10/mm , with a 6.42  10/mm neutrophil count .
the remaining laboratory tests performed were within the normal range : creatinine 61.1 mol / l , erythrocyte rate sedimentation at 30 mm / h , c - reactive protein
19.48 mg / l and her liver function tests were : aspartate transaminase 38 u / ml , bilirubin 9 mol / l and alkaline phosphatase 88 u / ml .
scattered neutrophils as well as eosinophils were noted within the dermis ( according to the euroscar score , the most of criteria have been met by our patient who had a score of 9 ) . within a week of piroxicam withdrawal ,
the patient remained on the same therapies for her arterial hypertension , diabetes mellitus and dyslipidemia .
agep is a rare pustular severe cutaneous adverse reaction that generally presents with an acute edematous erythema and small non - follicular sterile pustules mostly beginning in folds or face and within hours becomes diffuse .
skin symptoms are almost always accompanied by fever ( 38c ) and leukocytosis with a high neurophil count ( 7000/l ) .
other skin symptoms such as marked edema of the face , purpura , blisters and vesicles have been described .
additional systemic manifestations include mild eosinophilia , lymphadenopathy , acute renal failure and a mild elevation of liver enzymes .
the multinational epidemiological case - control study on severe cutaneous adverse reactions ( euroscar - project ) has developed and used the well - defined euroscar group criteria to establish the diagnosis of agep .
it allots 0 , 1 or 2 points for each of 4 variables of morphology , 10 , 0 , 1 , 2 or 3 for each of 5 variables of histological findings . in addition
, it assigns 4 , 2 , 0 or 1 for each of 5 items of the disease 's course . its involved items yield causality levels of definite with a scale at 8 - 12 points , probable ( 5 - 7 points ) , possible ( 1 - 4 points ) and excluded agep ( 0 point ) .
the euroscar score was 9 and therefore , the case was specified as definite agep .
histological findings show subcorneal and/or intraepidermal pustules , with pronounced edema in the papillary dermis and a perivascular infiltrate of neutrophils and eosinophils .
studies show that antibiotics were the most common drugs implicated ( 75% ) , with no attributes to non - steroidal anti - inflammatory drugs ( nsaids ) .
furthermore , there is an increasing number of cases caused by anti - fungals . a study done by chang et al .
analyzed 16 cases of agep with a relatively low association with systemic drugs ( 62.5% ) , there was no case of causative nsaids .
there have been few cases implicating nsaids , including ibuprofen , diclofenac , topical bufexamac , naproxen and phenylbutazone . as corticosteroids are commonly used in the treatment of severe agep
; they nevertheless , may trigger severe and rare agep . in this case , the clinical presentation and histology of a skin biopsy were consistent with agep .
the other medications ( nifedipine , captopril , indapamide , glibenclamide , glimepiride and simvastatin ) were continued .
this association could have been strengthened by performing patch test with piroxicam . due to the self - limited and benign course of this disease ,
treatment is usually not necessary except for symptomatic therapy and withdrawal of the culprit drug .
some cases have been treated with intravenous hydrocortisone , oral prednisolone or methylprednisolone or topical agents alone .
drugs like infliximab were used in an over lop of agep - toxic epidermal necrolysis . in our case , the withdrawal of piroxicam was sufficient to resolve all clinical features in only 1 week .
acute generalized exanthematous pustulosis ( agep ) is a severe adverse cutaneous reaction characterized by an acute episode of sterile pustules over erythematous - edematous skin . 
 the main triggering drugs are antibiotics , mainly beta - lactam and macrolides . 
 non - steroid anti - inflammatory drugs may rarely be responsible . 
 we describe a case of a woman with agep , who presented with generalized pustulosis lesions after the use of piroxicam for renal colic . 
 the diagnosis was confirmed by the clinical and histological correlations and the dermatosis resolved after withdrawal of the drug .