Acute Generalized Exanthematous Pustulosis Induced by HIV Postexposure Prophylaxis with Lopinavir-Ritonavir

Sir—Almost all available antiretroviral drugs can induce exanthema, but only a small number can cause life-threatening reactions [1, 2]. The drugs carrying the highest risk of causing severe cutaneous adverse reactions are nevirapine [3], efa-virenz [4], and the nucleoside analogue abacavir [5]. To our knowledge, no cases of acute generalized exanthematous pus-tulosis (AGEP) have been reported in HIV-infected patients. We report a case of AGEP induced by lopinavir-ritonavir in a health care worker receiving postexposure prophylaxis. A 39-year-old man was prescribed zi-dovudine, lamivudine, and lopinavir-rito-navir after occupational HIV exposure. He had no personal or familial history of pso-riasis and was not receiving any other treatment at the time of the accidental exposure. The results of an HIV immuno-sorbent assay performed before treatment were negative, and his WBC count was normal. Twenty-four hours after the first dose of antiretroviral combination pro-phylaxis, he developed generalized pruri-tus and a pustular rash that spread rapidly over the dorsal surface of the trunk and neck. The pustules were tiny and nonfol-licular, and arose on a diffuse erythema-tous background. His body temperature was 38.5ЊC. The findings of a physical examination were otherwise normal, with no mucosal involvement or palpable adenop-athy. Lopinavir-ritonavir treatment was immediately discontinued, and prophy-laxis with zidovudine and lamivudine was continued for a total of 28 days. His skin symptoms improved dramatically 48 h after withdrawal of lopinavir-ritonavir therapy , and there was marked desquamation. Samples of the pustules tested negative for bacterial and viral pathogens. Serologic tests retrospectively performed on samples obtained on the first day of prophylaxis suggested past exposure to Epstein-Barr virus and cytomegalovirus. The patient did not develop HIV infection during follow up. AGEP is a well-known severe skin disorder , most cases of which are drug-related [6, 7]. The main culpable drugs are antibiotics, some diuretics, azole antifun-gals, and chloroquine [8–11]. Viral infections can also trigger AGEP [12, 13]. Our patient had characteristic features of AGEP, including very rapid and acute onset after the first drug intake, a pustular eruption, and fever with a temperature of 138ЊC. The dramatic improvement and superficial desquamation observed when the lopinavir-ritonavir component of combination prophylaxis alone was withdrawn suggests that this component was responsible [6]. A similar case was reported in an HIV-seronegative subject receiving postexpo-sure prophylaxis that included zidovudine, lamivudine, and indinavir after unprotected sexual intercourse with an HIV-seropositive partner [14]. AGEP occurred 3 days after treatment initiation. The same regimen was …