September 1998

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History: The patient is a 36 year old white male who presentied with a 6 month history of a pruritic eruption. His past medical history was significant for a motor vehicle collision ten years prior to admission during which he suffered burns over 30-40% body surface area. He underwent skin grafts during the initial hospitalization. He subsequently developed contractures requiring release and repeated skin grafts first to his right axilla and elbow and subsequently to his right axilla again and right fifth finger six months later. These occurred on two separate occasions within ten months of the initial injury. He remained well until 6 months prior to admission to Washington University Medical Center. He had rapidly developed erythema, pruritus, and scaling in most of the grafted and donor sites, ulcerations on one hand, and exquisite pain in one site localized to his right calf.

Physical Examination: Revealed evident skin graft and donor sites on right upper extremity, right flank and chest, abdomen, back, both thighs and calves and left distal arm. The majority of these were found to have an erythematous, confluent, papular, scaly eruption that was sharply demarcated at the boundary of graft and donor sites (Fig. 1, 2). This mostly consisted of a dermal component with overlying epidermal changes. Several crusted ulcerations were noted on his right wrist. His right calf (a donor site) was tender to palpation, with honey-colored to black crusting on an erythernatous base measuring 8 x 25cm (Fig.3). Skin not involved with the initial bum injury or skin grafts, including the subsequent donor sites at later surgery, were free of any lesions.

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