Acute Generalized Exanthematous Pustulosis Due to Milk Thistle (Silybum marianum) Tea Pustulosis exantemática generalizada aguda debida a una infusión de cardo mariano (Silybum marianum)

Acute generalized exanthematous pustulosis (AGEP) is a rare disease that has been linked to certain drugs, such as antibiotics, antifungal agents, anticonvulsants, and antihypertensive agents. Other possible triggers that have been described include infection, pregnancy, allergens, spider bites, iodinated contrast media, herbal medicinal products, and tumors. In some cases, however, the causative agent cannot be identified. Several hypotheses that have been proposed to explain the pathogenesis of this skin reaction involve T lymphocytes and cytokines and posit that they are responsible for the characteristic neutrophilia and the aggregates of neutrophils in the histological picture of AGEP. It is recognized that previous sensitization, including contact sensitization, could explain some of these drug eruptions, and patch testing is positive in up to 80% of drug-related cases. A 45-year-old man with hyperuricemia on treatment with allopurinol for the previous 3 years consulted for an acute disorder that had started on the trunk 48 hours earlier and had spread to the face and limbs; he also reported fever and general malaise. Physical examination revealed erythema and edema of the skin of the face, trunk, and limbs----including the skinfolds and the palms----associated with multiple nonfollicular pustules (Fig. 1). There were also lesions on the oral mucosa and erosions on the lips. He did not report a history of infection and there had been no changes in the dose of his usual medication or new treatments added in the previous 3 months. However, he did remember taking milk-thistle infusions for a week before the onset of symptoms. The preparation, bought in a herbalist shop, contained dried seeds and was used by the patient to prevent dyspepsia. Histopathology of a lesion showed intraepidermal pustules, with edema of the papillary dermis and a predominantly neutrophilic perivascular inflammatory infiltrate. No acanthosis or papillomatosis was observed. The results of additional tests were as follows: white cell count, 16 500/ L (normal range, 4000-11 000/ L) (neutrophils,