acute generalized exanthematous pustulosis with mephenesin balm

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Acute generalized exanthematous pustulosis with mephenesin balm Pustulose exanthématique aiguë généralisée à la méphénésine Mephenesin is an aromatic glycerol ether which decreases polysynaptic transmission in the spinal cord and brain stem. It is used as a skeletal muscle relaxant in the treatment of multiple sclerosis, Parkinson’s disease or acute muscle strain [1,2]. Mephenesin is associated to methyl nicotinate in the Décontractyl W Balm. The methyl nicotinate has a rubifacient effect. Usually, the Décontractyl W Balm is well tolerated and associated with local cutaneous reactions. The presence of terpenic products in this balm may cause general side effects such as convulsions or confusions. Acute generalized exanthe- matous pustulosis (AGEP) is exceptional with this balm. We report a case of AGEP induced by topical application of Décontractyl W Balm. This case was notified to the National Centre of Pharmacovigilance of Tunis on the 10th of June 2012. Case report We relate a case of a 47-year-old man with history of eczema and local erythema episodes. He does not take any chronic treatment. On the 24th May 2012, by self-medication, he applied on his right flank the Décontractyl W Balm for myalgia. On the 25th May, an erythema localized on his right flank appeared which extended rapidly on the same day into small non-follicular pustules on the whole body. He had no mucous lesions. On the 26th of May, the patient was hospitalized. The dermatological examination found a generalized erythema saving the face, the neck, the folds (beside inguinal, popliteal), the palms and the soles. This erythema was well limited and scattered with non-follicular pustules measuring 0.3 cm of diameter and which became confluent in some places. This eruption was accompanied with fever around 38.5 8C. Hyper- leucocytosis (30,000/mL) and high neutrophil count (27,000/ mL) was found in the biological tests. An hypereosinophilia was also seen (600/mL). Biopsy found subcorneal pustules with a perivascular infiltrates of neutrophils and some eosinophils. Psoriatic changes as acanthosis and papillomatosis were ab- sent. The diagnostic of AGEP was retained. These features resolved spontaneously in about 3 to 4 days. Patch test (1% pet whole drug) was performed on the 1st of December 2012. The patch was applied on the back and was positive after 30 min with an erythematous papule. Discussion AGEP is a severe cutaneous reaction which can be induced by drugs. Systemic drugs are more often responsible such as antibiotics (macrolides, betalactamin antibiotics) [1,2]. Excep- tionally topic drugs were incriminated (bufexamac, lindane) [1,3,4]. In this case, the EuroSCAR score of AGEP [5] was 09 ‘‘definite’’ (the highest score) in front of: non-follicular pustules on the whole body with hyperthermia; the abrupt onset and the rapid evolution of the eruption (< 15 days); the subcorneal pustules and the perivascular infiltrates with neutrophils and some eosinophils on the biopsy; the high count of neutrophils above 7000/mL. The responsibility of Décontractyl W was retained in front of: the temporal relation delay with the single drug administrated; the beginning of the lesions at the site of application of the balm; the positive patch test to mephenesin and methyl nicotinate (erythema and edema). Local mephenesin application is associated in literature with local eruptions in few cases. All of them appeared in the mephenesin zone of application. It deals with purpuric derma- titis in one case [6], local vascularitis in another case [7] and erythema multiform in some other cases [8]. We have achieved a patch test with the whole product. Patch test in AGEP is fruitful. They have a significant value if they are positive [9]. An only mephenesin-patch test should be done to prove the imputability of the active principle. In conclusion, the Décontractyl W Balm is used commonly while its benefits are not yet very well established. It can be asso- ciated with serious adverse events. The balance benefits/risk of this product should be reconsidered after this second case of AGEP. Presse Med. 2014; //: /// en ligne sur / on line on www.em-consulte.com/revue/lpm www.sciencedirect.com 1 Letter to the editor tome // >n8/ > / LPM-2399 Please cite this article in press as: Lakhoua G et al., Acute generalized exanthematous pustulosis with mephenesin balm, Presse Med (2014), http://dx.doi.org/10.1016/j.lpm.2013.11.018.

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Page 1: Acute generalized exanthematous pustulosis with mephenesin balm

Presse Med. 2014; //: /// en ligne sur / on line onwww.em-consulte.com/revue/lpmwww.sciencedirect.com

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Please cite this article in press as: Lakhoua G et al., Acute generalized exanthematous pustulosis with mephenesin balm, PresseMed (2014), http://dx.doi.org/10.1016/j.lpm.2013.11.018.

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Acute generalizedexanthematouspustulosis withmephenesin balm

Pustulose exanthématique aiguë généralisée àla méphénésine

Mephenesin is an aromatic glycerol ether which decreasespolysynaptic transmission in the spinal cord and brain stem.It is used as a skeletal muscle relaxant in the treatment ofmultiple sclerosis, Parkinson’s disease or acute muscle strain[1,2]. Mephenesin is associated to methyl nicotinate in theDécontractylW Balm. The methyl nicotinate has a rubifacienteffect. Usually, the DécontractylW Balm is well tolerated andassociated with local cutaneous reactions. The presence ofterpenic products in this balm may cause general side effectssuch as convulsions or confusions. Acute generalized exanthe-matous pustulosis (AGEP) is exceptional with this balm.We report a case of AGEP induced by topical application ofDécontractylW Balm. This case was notified to the NationalCentre of Pharmacovigilance of Tunis on the 10th of June 2012.

Case report

We relate a case of a 47-year-old man with history of eczemaand local erythema episodes. He does not take any chronictreatment. On the 24th May 2012, by self-medication, heapplied on his right flank the DécontractylW Balm for myalgia.On the 25th May, an erythema localized on his right flankappeared which extended rapidly on the same day into smallnon-follicular pustules on the whole body. He had no mucouslesions. On the 26th of May, the patient was hospitalized. Thedermatological examination found a generalized erythemasaving the face, the neck, the folds (beside inguinal, popliteal),the palms and the soles. This erythema was well limited andscattered with non-follicular pustules measuring 0.3 cm ofdiameter and which became confluent in some places. Thiseruption was accompanied with fever around 38.5 8C. Hyper-leucocytosis (30,000/mL) and high neutrophil count (27,000/mL) was found in the biological tests. An hypereosinophilia was

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also seen (600/mL). Biopsy found subcorneal pustules with aperivascular infiltrates of neutrophils and some eosinophils.Psoriatic changes as acanthosis and papillomatosis were ab-sent. The diagnostic of AGEP was retained. These featuresresolved spontaneously in about 3 to 4 days.Patch test (1% pet whole drug) was performed on the 1st ofDecember 2012. The patch was applied on the back and waspositive after 30 min with an erythematous papule.

Discussion

AGEP is a severe cutaneous reaction which can be induced bydrugs. Systemic drugs are more often responsible such asantibiotics (macrolides, betalactamin antibiotics) [1,2]. Excep-tionally topic drugs were incriminated (bufexamac, lindane)[1,3,4].In this case, the EuroSCAR score of AGEP [5] was 09 ‘‘definite’’(the highest score) in front of:� non-follicular pustules on the whole body with hyperthermia;� the abrupt onset and the rapid evolution of the eruption

(< 15 days);� the subcorneal pustules and the perivascular infiltrates with

neutrophils and some eosinophils on the biopsy;� the high count of neutrophils above 7000/mL.The responsibility of DécontractylW was retained in front of: thetemporal relation delay with the single drug administrated; thebeginning of the lesions at the site of application of the balm;the positive patch test to mephenesin and methyl nicotinate(erythema and edema).Local mephenesin application is associated in literature withlocal eruptions in few cases. All of them appeared in themephenesin zone of application. It deals with purpuric derma-titis in one case [6], local vascularitis in another case [7] anderythema multiform in some other cases [8].We have achieved a patch test with the whole product. Patchtest in AGEP is fruitful. They have a significant value if they arepositive [9]. An only mephenesin-patch test should be done toprove the imputability of the active principle.In conclusion, the DécontractylW Balm is used commonly whileits benefits are not yet very well established. It can be asso-ciated with serious adverse events. The balance benefits/risk ofthis product should be reconsidered after this second case ofAGEP.

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LPM-2399

Page 2: Acute generalized exanthematous pustulosis with mephenesin balm

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Please cite this article in press as: Lakhoua G et al., Acute generalized exanthematous pustulosis with mephenesin balm, PresseMed (2014), http://dx.doi.org/10.1016/j.lpm.2013.11.018.

Letter to the editor

Disclosure of interest : the authors declare that they have no conflicts ofinterest concerning this article.

References[1] Roujeau JC, Bioulac-Sage P, Bourseau C, Guillaume JC, Bernard P, Lok C

et al. Acute generalized exanthematous pustulosis. Arch Dermatol

1991;127:1333-8.[2] Saissi EH, Beau Salinas F, Jonville Bera AP, Lorette G, Autret-Leca E,

Centres régionaux de pharmacovigilance. Médicaments associés à lasurvenue d’une pustulose exanthématque aiguë généralisée. AnnDermatol Venerol 2003;130:612-8.

[3] Benhadjali H, Ghannouchi N, Njim L, Mohamed M, Moussa A, Bayou Fet al. Acute generalized exanthematous pustulosis induced by bufexa-

mac in an atopic girl. Contact Dermatitis 2008;58:247-8.[4] Juan WH, Yang LC, Hong HS. Acute generalized exanthematous

pustulosis induced by topical lindane. Dermatology 2004;209:239-40.[5] Sidoroff A, Dunant A, Viboud C, Halevy S, Bavinck JN, Naldi L et al. Risk

factors for acute generalized exanthematous pustulosis (AGEP) – Results

of a multinational case-control study (EuroSCAR). Br J Dermatol

2007;157:989-96.[6] Bachmeyer C, Blum L, Fléchet ML, Duriez P, Cabane J, Imbert JC. Dermite de

contact grave à la méphénésine. Ann Dermatol Venerol 1996;123:185-7.[7] Delbarre M, Joly P, Balguerie X, Thomine E, Lauret P. Vascularite de

contact aux topiques contenant des anti-inflammatoires non stéroïdiensou des antalgiques. Ann Dermatol Venarol 1997;124:841-4.

[8] Degreff H, Bonamie A, Vanderheyden D, Dooms-Goossens A. Mephe-nesin contact dermatitis with erythema multiform features. ContactDermatitis 1984;10:220-3.

[9] Wolkenstein P, Chosidow O, Fléchet ML, Robbiola O, Paul M, Dumé Let al. Patch testing in severe cutaneous drug reactions, includingStevens-Johnson syndrome and toxic epidermal necrolysis. ContactDermatitis 1996;35:234-6.

Ghozlane Lakhoua1,2, Sihem El Aidli1,2, Ahmed Zaïem1,2,Rym Ben Mously2,3, Ehsen Ben Brahim2,4, Riadh Daghfous1,2

1National Center of Pharmacovigilance, 9, avenue du Dr Zou-haier Essafi, 1006 Tunis, Tunisia

2Tunis El Manar University, Medicine Faculty, 15, rue DjebelLakhdhar, La Rabta, 1007 Tunis, Tunisia

3Hôpital Habib Thameur, service de dermatologie, rue de Bab ElFella, 2004 Tunis, Tunisia

4Hôpital Habib Thameur, service d’anatomopathologie, rue deBab El Fella, 2004 Tunis, Tunisia

Correspondence: Ghozlane Lakhoua,National Center of Pharmacovigilance, 9, avenue du Dr Zouhair

Essafi, 1006 Tunis, [email protected]

Received 11 July 2013Accepted 18 November 2013

� 2014 Elsevier Masson SAS. All rights reserved.http://dx.doi.org/10.1016/j.lpm.2013.11.018

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