Case Presentation
A 41-year-old male presents to the clinic with a chief complaint of
fever and rashes for the past two days. The fever had a gradual onset
and was relieved upon taking medication. The patient reports a maximum
temperature of 100°F and denies experiencing chills or rigor. The rashes
initially appeared on the neck and gradually spread throughout the
entire body, including the hands, legs, and feet. The rashes started as
small erythematous papules and enlarged with central necrosis. The
patient also reports a history of taking diclofenac tablets for two
days, which was approximately four days before the onset of the rash. No
other significant medical history is reported, including the absence of
respiratory symptoms, chest pain, gastrointestinal symptoms, jaundice,
photosensitivity, urinary symptoms, a history of rash in the past, or
any history of red or frothy urine. The patient denies any recent
travel, intravenous drug use, or promiscuous sexual habits. The patient
provides a history of using steroids after the onset of symptoms.
On physical examination, multiple violaceous plaques with central
necrosis and a peripheral erythematous to hypopigmented halo are
observed over the anterior neck, abdomen, posterior back, bilateral
dorsum of the hands, soles, bilateral lower limbs, and feet. The
patient’s nails demonstrate splinter hemorrhages, nail fold erythema,
and red lunula. The patient’s vital signs are as follows: pulse rate of
100 beats per minute, temperature of 100°F, blood pressure of 180/80
mmHg, and oxygen saturation level of 96%.
Laboratory investigations reveal a hemoglobin level of 10.21 g/dL, a
total leukocyte count of 4830 cells/mm³, and a random blood sugar level
of 158 mg/dL. The erythrocyte sedimentation rate was 35 mm/hr (reference
range: 0-20). The liver function test and renal function test were
normal. Serological tests revealed positive antinuclear antibodies (ANA)
with a speckled pattern, positive anti-double-stranded DNA (anti-dsDNA)
antibodies, and positive rheumatoid factor (RF). However, the tests for
scrub typhus, brucella antibodies, leptospirosis, and typhoid were
negative. HIV, HBsAG, and HCV were non-reactive.
A wound swab was sent for culture, which came sterile. A skin biopsy was
performed on the right forearm, and the histopathological examination
revealed a skin fragment lined by keratinized stratified squamous
epithelium. The biopsy showed areas of ulceration, follicular plugging,
and mixed inflammatory cell exocytosis. As shown in the figure 4, the
dermis exhibited edema and hemorrhage, with thrombi formation and
degenerated endothelial cells in a few vessels. Dense mixed inflammatory
infiltrates were observed throughout the dermis, primarily in the
peripilar unit, including the perivascular region. The erector pili
muscle appeared unremarkable, while the subcutis was scant and
unremarkable. Focal areas showed subepidermal bulla and lymphocytic
infiltration at the dermo-epidermal junction.
Based on the patient’s clinical presentation, including the fever, a
characteristic rash with central necrosis and peripheral halo, oral
ulcers, nail hemorrhages, positive anti-dsDNA antibodies, and a positive
ANA with a speckled pattern, the initial differential diagnoses to
consider include systemic lupus erythematosus (SLE) and bullous erythema
multiforme.
Our patient was subsequently managed with hydroxychloroquine,
prednisolone, steroid ointment, a proton pump inhibitor, and sunscreen
cream after the diagnosis. Following the treatment, the skin lesions
gradually resolved. The skin lesions during presentation, over a period
of 3 weeks and 6 weeks, are shown in figures 1, 2, and 3.