July 2006






History: A 49 year-old African American female presented with a 1 month history of a diffuse skin eruption. She reported that the eruption was at first mild and became severe 1 week prior to presentation. The eruption was pruritic and not painful. She denied eye pain, abdominal pain, dysuria, chest pain, dyspnea, myalagia, or arthralgias. She reported an intermittent fever for 3 weeks and facial edema. Past medical history was significant for a subarachnoid hemorrhage 6 weeks prior to presentation from a ruptured aneurysm which was treated with cerebral anuerysm clipping. She started Dilantin at this time (6 weeks prior to presentation) as seizure prophylaxis. Other medications included atenolol, lisinopril, and aspirin.
Physical Examination: Vital signs at presentation were: temperature 39.4 °C, blood pressure 140/90, heart rate 118, and respiratory rate 18. She had significant facial edema with numerous pustules and yellow crust (fig.1).Her skin revealed an erythroderma with red papules on her arms and legs some of which were vesiculated (fig.2). Her lips had yellow crust, but she did not have mucosal involvement of the oropharynx, conjunctiva, or vagina. She had an enlarged right anterior cervical lymph node.
Lab findings: Electrocardiogram revealed sinus tachycardia. Laboratory analysis revealed a WBC of 4.6 x 103/mcl, hemoglobin of 11.6 g/dL, and platelet count of 33 x 103/mcl. The platelet count normalized without transfusion of platelets suggesting that the initial value was a laboratory error. Her eosinophil count was 1.1 x 103/mcl (24% of the WBC). A complete metabolic panel was significant for a slightly elevated AST and ALT of 63 and 58, respectively.


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