People living with human immunodeficiency virus (PLHIV) are 100 times more at risk for cutaneous adverse drug reactions (ADRs). Acute generalized exanthematous pustulosis (AGEP) is a rare and severe cutaneous ADR associated with systemic involvement in 20% of cases.

This is a case of a 30-year-old male living with HIV admitted for acute gastroenteritis. Eight hours after initiation of intravenous ciprofloxacin and metronidazole, the onset of generalized monomorphic asymptomatic pustules was observed with associated weakness, fever, thrombocytosis, and neutrophilia. Ciprofloxacin was shifted to piperacillin-tazobactam. The patient was managed with intravenous hydrocortisone and oral cetirizine. Thereafter, the lesions remained stable in size and no new lesions occurred. The patient was referred to the dermatology service for further evaluation and management. A diagnostic workup was done which revealed subcorneal pustular dermatitis on histopathology, no fungal elements on periodic acid-Schiff stain, negative Gram stain, and no growth on culture. This case was diagnosed as AGEP secondary to ciprofloxacin. Dermatologic management consisted of oral antihistamines and topical steroids. The patient experienced generalized desquamation and gradual resolution of pustules over a two-week period with the eventual appearance of normal skin.

Ciprofloxacin is commonly used to treat opportunistic infections in the setting of HIV but it has never been documented to cause AGEP in such settings. Decreased CD4+ T-cell count (460 cells/µL) are factors associated with drug eruptions. Despite its toxic presentation, AGEP has a good prognosis with prompt withdrawal of the offending drug and supportive management.