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Skin rash following amoxicillin treatment

      Keywords

      1. Case description

      A 26-year-old woman presented with a chief complaint of nausea for 2 days. On the previous day, she had been diagnosed with tonsilitis by her previous doctor because of fever and sore throat, and had started treatment with amoxicillin. On examination, bilateral enlarged tonsils with white spots were observed. Blood tests showed elevation of hepatic transaminase and lactate dehydrogenase levels. We suspected acute hepatitis because of her recent consumption of undercooked beef and elevation of hepatitis type A antibody. At 1 week after initiating amoxicillin treatment, she complained of generalized rashes. Flushing of the face, avoiding the eye area, with painless posterior cervical adenopathy and generalized erythematous papules and macules on the trunk and limbs, except below the knees, were confirmed (Figs. 1a and 1b). What is the diagnosis?
      Fig 1
      Fig. 1The patient's skin manifestation at 1 week after initiating amoxicillin treatment. Generalized erythematous papules and macules involving her arms (a) and legs except below the knees (b) were observed.

      2. Diagnosis

      Blood tests revealed the presence of atypical lymphocytes. Epstein-Barr (EB) virus capsid antigen (VCA) IgM and VCA-IgG antibodies were confirmed to be elevated without elevation of EB virus nuclear antigen titer. Because the patient reported sexual contact with her boyfriend at 2 and 23 days before the onset of symptoms, the diagnosis of EB virus infectious mononucleosis was made. The generalized rashes were therefore caused by treatment with amoxicillin.

      3. Discussion

      Infectious mononucleosis is characterized by fever, tonsillar pharyngitis, and lymphadenopathy and mainly caused by EB virus infection [
      • Ebell MH.
      Epstein-Barr virus infectious mononucleosis.
      ]. Although more than 90% of infectious mononucleosis cases are triggered by EB virus [
      • Fugl A
      • Andersen CL.
      Epstein-Barr virus and its association with disease - a review of relevance to general practice.
      ], fever, pharyngitis, and lymphadenopathy can also be caused by group A streptococcus, cytomegalovirus (CMV), and acute human immunodeficiency virus (HIV) or Toxoplasma gondii [
      • Ebell MH.
      Epstein-Barr virus infectious mononucleosis.
      ,
      • Fugl A
      • Andersen CL.
      Epstein-Barr virus and its association with disease - a review of relevance to general practice.
      ]. Lymphocytosis, an increased proportion of atypical lymphocytes, and elevated hepatic transaminase levels are primary diagnostic clues to suspect infectious mononucleosis. Skin eruption during EB virus infection is characterized by generalized maculopapular, urticarial, or petechial rash involving the palms and soles following administration of amoxicillin or other antibiotics [
      • Ciccarese G
      • Trave I
      • Herzum A
      • Parodi A
      • Drago F.
      Dermatological manifestations of Epstein-Barr virus systemic infection: a case report and literature review.
      ]. The differential diagnosis for these skin lesions is Gianotti–Crosti syndrome, Stevens–Johnson syndrome, or virus infections such as varicella zoster virus and enterovirus [
      • Ciccarese G
      • Trave I
      • Herzum A
      • Parodi A
      • Drago F.
      Dermatological manifestations of Epstein-Barr virus systemic infection: a case report and literature review.
      ]. Clinicians should be aware that use of antibiotics such as amoxicillin in patients with EB virus infectious mononucleosis can often lead to generalized maculopapular rash.

      Funding

      This work was supported by the Japan Medical Education Foundation (https://www.jmef.or.jp/). The funders had no role in the preparation of the manuscript or the decision to publish.

      References

        • Ebell MH.
        Epstein-Barr virus infectious mononucleosis.
        Am Fam Physician. 2004; 70: 1279-1287
        • Fugl A
        • Andersen CL.
        Epstein-Barr virus and its association with disease - a review of relevance to general practice.
        BMC Fam Pract. 2019; 20: 62https://doi.org/10.1186/s12875-019-0954-3
        • Ciccarese G
        • Trave I
        • Herzum A
        • Parodi A
        • Drago F.
        Dermatological manifestations of Epstein-Barr virus systemic infection: a case report and literature review.
        Int J Dermatol. 2020; 59: 1202-1209https://doi.org/10.1111/ijd.14887