Icodextrin– induced acute generalized exanthematous pustulosis in a patient with peritoneal dialysis

Abstract Icodextrin is widely utilized as an osmotic agent in peritoneal dialysis (PD) prescription for clinical patients with inadequate ultrafiltration, but icodextrin induced acute generalized exanthematous pustulosis (AGEP) has not been well recognized. We described a young-aged female with IgA nephropathy under continuous automated peritoneal dialysis who developed skin erythema with exfoliation over the groin at 7 th day after first infusion of icodextrin based PD prescription. Her scaling skin lesion with pinhead-sized pustules invaded the bilateral inguinal folds at first, and then extended to general trunk accompanied by pruritus and mild tingly in rapid succession. As expansion of confluent skin lesion, she was admitted on 14 th day of icodextrin exposure and PD treatment was instantly ceased. She was afebrile with stable vital sign and physical examination was notable for widespread erythematous papules with pruritus extending over her groins, abdomen and back. Pertinent laboratory examination showed leukocytosis of 18970 cells/μL with neutrophile count of 17642 cells/μL (92.3 %), and c-reactive-protein: 3.39 mg/dl. Skin biopsy reveals multifocal subcorneal abscess with papillary dermal edema, and upper-dermal neutrophilia with perivascular accentuation, consistent with the diagnosis of AGEP. After discontinuation of PD, she underwent temporary high-flux hemodialysis and treatment of steroid and antihistamine, her dermatologic lesion resolved totally four days later and restarted peritoneal dialysis at 17 th day without any skin sequalae. This case highlighted the fact that icodextrininduced AGEP should be early recognized after first use of icodextrin to avoid misdiagnosis to other dermatoses and severe complication without appropriate management.