THE CLINICAL PICTURE TIMMIE SHARMA, MD ALOK VIJ, MD APRA SOOD, MD Department of Dermatology, Department of Dermatology, Head, Section of Industrial Dermatology, University Hospitals Case Medical Center, Cleveland Clinic Department of Dermatology, Cleveland, OH Cleveland Clinic
Fungal folliculitis masquerading as acute exanthematous pustulosis
25-year-old man being treated in the A hospital for catatonia and fl accid paraly- sis developed fever and a lobar consolidation, prompting treatment with piperacillin-tazo- bactam. A dermatology consult was called 3 days later when the patient developed a rash on the forehead (Figure 1), cheeks, chin, and upper trunk, raising concern for a drug-related eruption. Close examination of the rash revealed bright red plaques studded with sheets of monomorphic pustules. Possible causes other than drug therapy were considered, includ- ing folliculitis, acneiform eruption, and pus- tular psoriasis. Bacterial culture of a pustule was negative, but punch biopsy of a pustule FIGURE 1. A brightly erythematous plaque on the revealed an abundance of round and oval bud- forehead with monomorphic pustules was noted ding yeast forms consistent with Malassezia on day 3 of piperacillin-tazobactam infusion. (formerly called Pityrosporum) “stuffi ng” the hair follicles and forming cleared spaces in the of acute generalized exanthematous pustulosis. dermis surrounded by an exuberant lympho- It is a serious but uncommon adverse drug re- histiocytic infi ltrate (Figures 2 and 3). Spe- action, with a frequency of one to fi ve cases cial stains were negative for bacteria and my- per million per year. The eruption of erythem- celial forms. The clinicopathologic fi ndings atous plaques studded with sterile pustules were diagnostic of Malassezia folliculitis with classically appears 1 to 5 days after starting a formation of dermal abscesses. drug.1 Piperacillin-tazobactam has been infre- The patient was treated with intravenous quently reported in association with acute ex- itraconazole 200 mg daily for 7 days and topi- anthematous pustulosis, but antibiotics in gen- cal benzoyl peroxide 5% gel, with ketocon- eral are among the most commonly reported azole 2% cream for maintenance therapy. culprits.2–4 The treatment brought improvement of the rash. Clues to the correct diagnosis Although our concern for acute localized ex- ■ THE DIFFERENTIAL DIAGNOSIS anthematous pustulosis was warranted, the morphology and distribution of this patient’s The appearance of sterile pustules after start- exanthem also raised suspicion of fungal fol- ing a new antibiotic raised suspicion for acute liculitis, which is more common. localized exanthematous pustulosis, a variant Malassezia folliculitis appears as a mono- morphic papular and pustular eruption on the doi:10.3949/ccjm.83a.15028 chest, back, and face,5 as in our patient. Differ-
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FIGURE 2. Histologic sections reveal Mal- FIGURE 3. Histologic sections of a perifol- assezia folliculitis and abscess formation licular dermal abscess show mixed infl am- within the dermis. The red circle highlights matory infi ltrate including neutrophils and yeast forms within the follicular epithelium histiocytes centered on cleared-out spaces (hematoxylin and eosin, × 4). with small, grey-blue yeast forms (red ar- row) (hematoxylin and eosin, × 100). entiating fungal folliculitis from pustulosis is Take-home point important, as each condition is treated differ- Our experience with this patient was a re- ently: Malassezia folliculitis is treated with an- minder to consider fungal folliculitis in the tifungals,5 and acute localized exanthematous differential diagnosis of a pustular eruption, pustulosis is managed with cessation of the of- so as to allow appropriate management and fending drug, supportive care, and systemic or to avert discontinuation of potentially life- topical steroids.4 saving medications. ■ A rash that ■ REFERENCES 1. Fernando SL. Acute generalised exanthematous pustulo- 4. Huilaja L, Kallioinen M, Soronen M, Riekki R, Tasanen K. developed sis. Australas J Dermatol 2012; 53:87–92. Acute localized exanthematous pustulosis on inguinal 3 days after 2. Talati S, Lala M, Kapupara H, Thet Z. Acute generalized area secondary to piperacillin/tazobactam. Acta Derm exanthematous pustulosis: a rare clinical entity with use Venereol 2014; 94:106–107. Rubenstein RM, Malerich SA starting of piperacillin/tazobactam. Am J Ther 2009; 16:591–592. 5. . Malassezia (pityrosporum) Sidoroff A, Dunant A, Viboud C, et al folliculitis. J Clin Aesthet Dermatol 2014; 73:37–41. piperacillin- 3. . Risk factors for acute generalized exanthematous pustulosis (AGEP)- ADDRESS: Alok Vij, MD, Department of Dermatology, A61, tazobactam results of a multinational case-control study (EuroSCAR). Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; Br J Dermatol 2007; 157:989–996. e-mail: [email protected] prompted concern for exanthematous pustulosis
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