63 year old African American woman with a history of systemic lupus erythematosus, lupus nephritis, and hypertension was admitted to Barnes Jewish Hospital for progressive odynophagia. Dermatology was consulted for lip and oral ulcers that developed one day after admission. The patient stated that she had not been taking any medication for her lupus or her HTN for 6 months prior to admission. HSV and CMV PCR from lip swab was obtained as well as biopsy of the lip for H&E and direct immunofluorescence, and the patient was started on empiric IV acyclovir and topical penciclovir pending culture and biopsy results.
Past Medical History: SLE, lupus nephritis, HTN, thyroid nodules (stable), pancytopenia (bone marrow biopsy at outside hospital revealed dysplasia without evidence of lymphoma)
Allergies: No known drug allergies
Medications: previously on plaquenil (discontinued 6 mos ago due to concerns about retinopathy), fluconazole (for presumptive esophagitis), esomeprazole, lisinopril, trazodone
Physical Exam: several erosions and intact vesicles of lips and oral mucosa (Fig. 1) as well as cutaneous blisters on dorsal hands (Figs. 2,3), elbows, (Fig. 4) and traumatized skin
Esophagogastroduodenoscopy: Revealed several superficial esophageal ulcers and few gastric ulcers; tissue and viral cultures including CMV PCR were negative. Esophageal biopsy and GMS stain negative for fungus.
Laboratory Data: WBC 3,900; Hgb 11.6; platelets 99; low complement levels with C3 of 38 and C4 of 6; double-stranded DNA high at 803.3; HIV negative, HCV RNA undetectable
Click here for the Diagnosis.