RSV infection-associated pediatric generalized pustular psoriasis with innate immune activation: a case report

Generalized pustular psoriasis (GPP) in infancy is uncommon and is often precipitated by infection, drugs, or systemic inflammatory responses. Although viral illnesses such as influenza have been reported to trigger GPP, acute exacerbation secondary to respiratory syncytial virus (RSV) is rarely described. We report a case of a 2-year-old girl with a prior history of mild psoriasis who developed widespread sterile, small pustules several days after onset of RSV infection symptoms (cough and low-grade fever), consistent with an RSV-associated acute exacerbation of GPP. Laboratory testing was positive for RSV nucleic acid and showed markedly elevated inflammatory markers. The family denied any use of over-the-counter medications prior to rash onset; based on the timing of lesion appearance and characteristic histopathology on skin biopsy (subcorneal pustules, Kogoj pustules, and psoriasiform epidermal hyperplasia), acute generalized exanthematous pustulosis (AGEP) was excluded. Treatment and follow-up: the patient received oral acitretin combined with intravenous immunoglobulin and albumin, after which the cutaneous lesions resolved rapidly. At 1-month post-discharge follow-up, the condition remained stable without recurrence. RSV infection should be recognized as a potential trigger for acute exacerbation of GPP in young children. In febrile acute pustular eruptions, viral nucleic acid testing and histopathological examination are important to enable early, targeted intervention.