[Methylprednisolone-induced acute generalized exanthematous pustulosis]. / Pustulose exanthématique aiguë généralisée à la méthylprednisolone.

BACKGROUND: Acute generalized exanthematous pustulosis is a rare drug allergy. Generalized reactions to systematically administrated corticosteroids are even rarer. We report the first case of acute generalized exanthematous pustulosis due to methylprednisolone. CASE REPORT: A thirty year-old-woman presented, a few hours after intravenous administration of methylprednisolone indicated for multiple sclerosis, a maculopapulous rash predominant in the folds rapidly becoming pustulous with malaise, fever and neutrophilia. The histologic examination and negativity of microbiological cultures were consistent with the diagnostic of acute generalized exanthematous pustulosis. The rash cleared spontaneously in one week with normalization of the biology. One month later, epicutaneous tests, confirmed the allergy to group A corticosteroids. The treatment of multiple sclerosis was pursued with dexamethasone. DISCUSSION: Clinical and histological manifestations were consistent with the diagnostic of acute generalized exanthematous pustulosis to methylprednisolone. Generalized reaction to systematically administered corticosteroids are very rare. Immediate reactions are the most frequently reported reactions, only about thirty delayed-type generalized skin eruptions have been reported to date. Group A corticosteroids are the most frequent causal agent. Epicutaneous tests have good sensitivity for acute generalized exanthematous pustulosis, for allergy to corticosteroids, delayed results are very important.

Patch testing in severe cutaneous adverse drug reactions, including Stevens-Johnson syndrome and toxic epidermal necrolysis.

Patch testing may help to assess the culpability of a drug in an adverse reaction. Our aim was to study patch testing in severe cutaneous adverse drug reactions (ADRs) (Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN), acute generalized exanthematous pustulosis (AGEP), and other cutaneous ADRs). 59 patients with cutaneous ADRs were included: 22 had SJS/TEN, 14 AGEP, and 23 other cutaneous ADRs. Patients were patch tested with the suspect drug, and with a standard series of drugs. 2 patients among the 22 SJS/TEN cases had a relevant positive test. 7 patients among the 14 AGEP cases had a relevant positive test. 6 patients among the 23 other cutaneous ADRs had a relevant positive test. Our results suggest that patch testing has a weak sensitivity in SJS/TEN and is not appropriate in these diseases. Patch testing seems more adapted to other cutaneous ADRs, such as AGEP, in which the proportion of positive patch tests was significantly higher (p < 0.02). Nevertheless, the difference of sensitivity of patch testing in SJS/ TEN, AGEP or other cutaneous ADRs could be linked not only to the clinical type of eruption, but also to the different spectrum of culprit drugs in each type of eruption.

[Severe contact dermatitis caused by mephenesin]. / Dermite de contact grave à la méphénésine.

INTRODUCTION: Mephenesin is a muscle relaxant, mostly applied locally in trauma. It is a component of Traumalgyl cream in association with phenylbutazone. Contact dermatitis due to mephenesin is exceptional. CASE REPORT: We report here a case of a woman who developed after application of Traumalgyl cream purpuric dermatitis, erythema multiforme-like and urticarial lesions. Patch-tests were strongly positive (+ + +) for both Traumalgyl cream and mephenesin and (+) for phenylbutazone. Improvement of the lesions was observed within 3 weeks. DISCUSSION: Physicians must be aware of the risk of severe contact dermatitis after application of products including mephenesin because of their widely prescription.

Inflammatory nodular reactions after hepatitis B vaccination due to aluminium sensitization.

In 2 patients, pruritic nodules appeared after revaccination against hepatitis B. Aluminium was found to be responsible for this side effect: contact allergy to aluminium was present in both patients, whereas controls were negative.

Toxic epidermal necrolysis (Lyell syndrome). Incidence and drug etiology in France, 1981-1985.

We looked retrospectively for all cases of toxic epidermal necrolysis that occurred in France over a 5-year period to appreciate the incidence of this disorder and its drug etiology. Of the 399 cases identified, we obtained detailed information on 344 cases and validated 253 cases. From response rates (66% to 98%), we estimated the actual total number of cases to be 333, and the incidence of toxic epidermal necrolysis in France to 1.2 cases per million per year. An independent estimation derived from death certificates gave a figure of 1.3 cases per million per year. When the number of cases with a given drug present were related to the defined daily doses of that drug sold over the 5-year period, the highest ratios were for sulfadiazin (230.10(-8], isoxica (41.10(-8], oxyphenbutazone (18.10(-8], phenytoin (14.10(-8], fenbufen (13.10(-8], and cotrimoxazole (12.10(-8]. This first nationwide study confirmed the rarity of toxic epidermal necrolysis. Within the two main classes of responsible drugs (antibacterial sulfonamides and nonsteroidal anti-inflammatory agents) the risks linked to different drugs appeared quite different, even for closely chemically related products.

[Osteoarticular manifestations of pustulosis palmaris et plantaris]. / Les manifestations ostéo-articulaires de la pustulose palmo-plantaire.

In 6 patients with clinically and histologically proven pustulosis palmaris et plantaris the disease was complicated by osteo-articular manifestations. Five patients presented with articular symptoms and one with aseptic subacute osteomyelitis. The distribution of these bone and joint disorders was different from that of Sonozaki's "pustulotic arthro-osteitis": in contrast with the latter, the anterior chest was inconstantly involved whereas the spine, sacro-iliac joints and peripheral articulations were more frequently affected. Although the B27 antigen is usually absent, it seems possible to classify the rheumatic disorders of pustulosis palmaris et plantaris among seronegative spondylo-arthropathies.

Plasma exchange in pemphigus. Uncontrolled study of ten patients.

Plasma exchange, together with oral immunosuppressive drugs and various doses of adrenal steroids, were used in the treatment of ten patients with pemphigus. Initially plasma exchange decreased the intercellular antibody (IC Ab) level in all patients and induced a clinical improvement in the conditions of eight of ten patients. This improvement was sustained for the six patients who received simultaneously 0.5 mg/kg/day or more of prednisone. Among the eight patients, four previously corticoresistant patients had perfect control of their disease. Conversely the other four patients, treated with low doses of prednisone, experienced a posttreatment rebound in IC Ab level and showed no or only transient clinical improvement. Plasma exchange may be useful in bringing corticoresistant pemphigus under control but it is not to be used without accompanying high doses of adrenal steroids.

[Charcot's blue edema, a case]. / L'oedème bleu de Charcot. Une observation.

The case of an 18 year old Algerian girl with acrocyanosis of the four extremities since childhood and presenting a with 6 months history of oedema of the left hand resulting in severe functional handicap, is reported. Clinically, the oedema suggested a lymphatic origin. However, its localised, strictly unilateral distribution, the normality of vascular investigations, the absence of pain and regression of the oedema during the period of hospitalisation suggested autoaggression. The discovery of tourniquet marks on the skin of the thigh confirmed the diagnosis of Charcot's blue oedema. The patient has a hysterical personality, was of higher than normal intelligence but immature, and could only express herself through her functional handicap, a cry for affection in a rigid family environment only concerned by her scholastic achievements. To our knowledge, there have been 27 other reports of this condition since Charcot's first description in 1890. The majority concerned young intelligent women. Diagnosis is difficult and can only be confirmed by the finding of tourniquet marks on the skin. Psychotherapy is often useful as an underlying neurotic or psychotic personality is commonly found.