ABSTRACT
BACKGROUND: Fixed drug eruptions (FDE) are peculiar drug rashes that tend to be violaceous, hyperpigmented, and round to oval-shaped plaques with dusky gray centers. The lesions tend to recur in a similar dermatologic distribution upon re-exposure to the offending medication, leading to intensified inflammation and sometimes the formation of blisters, bullae, and erosions. This bullous form of FDE can be mistaken clinically for Stevens Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN). CASE REPORT: We report two cases of patients presenting to the emergency department (ED) with characteristic blistering skin lesions and reports of similar prior episodes; both patients were initially diagnosed in the ED as "recurrent SJS" and admitted to the burn intensive care unit. Each patient was evaluated emergently by dermatology consultants, identified as cases of FDE rather than SJS, and transferred to the general medical ward with an uncomplicated hospital course and complete re-epithelialization within 7 days after removal of the inciting agent. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We discuss distinguishing features of bullous FDE and SJS/TEN in order to highlight this entity and aid in diagnostic accuracy and appropriate management by emergency physicians. In cases identified as classic or suspected SJS/TEN, the patient warrants aggressive resuscitation and admission to a burn unit, while cases identified as obvious bullous FDE can be managed much more conservatively. Although the clinical clues outlined here may help distinguish classic cases of FDE from SJS/TEN, it is always advisable to admit to a higher level of care or obtain an urgent dermatology consult when diagnostic uncertainty remains.
Subject(s)
Blister/chemically induced , Drug Eruptions/diagnosis , Stevens-Johnson Syndrome/diagnosis , Adult , Anti-Bacterial Agents/adverse effects , Anti-Inflammatory Agents, Non-Steroidal/adverse effects , Diagnosis, Differential , Drug Eruptions/etiology , Female , Humans , Ibuprofen/adverse effects , Male , Recurrence , Trimethoprim, Sulfamethoxazole Drug Combination/adverse effectsABSTRACT
IMPORTANCE: Small studies have implicated the association of specific autoantibodies with morphea subtype or severity, but no large-scale studies have been conducted. This prospective case-control study confirmed the presence of antinuclear antibodies (ANAs) and other autoantibodies in morphea but found they are of limited significance. OBJECTIVE: To determine the prevalence of ANAs, extractable nuclear antigens such as antihistone antibodies (AHAs), and anti-single-stranded DNA antibodies (ssDNA abs) in patients with morphea vs a healthy control population and their association with clinical measures of morphea severity. DESIGN, SETTING, AND PARTICIPANTS: Nested case-control study, conducted at the University of Texas Southwestern Medical Center, Dallas, and University of Texas Health Science Center, Houston. Study participants included individuals enrolled in the Morphea in Adults and Children (MAC) cohort and Scleroderma Family Registry and DNA Repository. MAIN OUTCOMES AND MEASURES: Prevalence of ANAs, AHAs, ssDNA abs in patients with morphea vs matched controls and association of the presence of autoantibodies with clinical indicators of morphea severity. RESULTS: The prevalence of ANAs, AHAs, and ssDNA abs in patients with morphea was 34%, 12%, and 8%, respectively. Antinuclear antibodies and AHAs, but not ssDNA abs, were present more frequently in cases than in controls. There was no difference in ANA prevalence among morphea subtypes. Among patients with linear morphea, the presence of autoantibodies was associated with clinical indicators of severe morphea including functional limitation (ssDNA ab, P = .005; and AHA, P = .006), extensive body surface area involvement (ssDNA ab, P = .01; and ANA, P = .005), and higher skin scores (ANA, P = .004). The presence of autoantibodies was not associated with clinical measures of morphea activity. CONCLUSIONS AND RELEVANCE: Our results demonstrate that ANAs and AHAs are more prevalent among patients with morphea but are of limited clinical utility except in linear morphea, where their presence, although infrequent, is associated with greater lesion burden and functional impairment.
Subject(s)
Antibodies, Antinuclear/immunology , Autoantibodies/immunology , DNA, Single-Stranded/immunology , Histones/immunology , Scleroderma, Localized/immunology , Adolescent , Adult , Age Factors , Body Surface Area , Case-Control Studies , Child , Cohort Studies , Female , Humans , Male , Middle Aged , Prevalence , Prospective Studies , Severity of Illness IndexSubject(s)
Carcinoma, Squamous Cell/drug therapy , Head and Neck Neoplasms/drug therapy , Neoplasm Recurrence, Local/drug therapy , Scalp/pathology , Skin Neoplasms/drug therapy , Aged, 80 and over , Carcinoma, Squamous Cell/secondary , Complementary Therapies/adverse effects , Humans , Lymphatic Metastasis , Male , Necrosis/chemically induced , Ointments/adverse effects , Plant Extracts/adverse effects , Sanguinaria/adverse effectsABSTRACT
Cutaneous fusariosis is an opportunistic mycosis in immunocompromised patients. We present a novel variation of an immunocompromised patient who developed fusariosis in a previously irradiated site. Irradiation led to atrophy, contraction, fibrosis, barrier disruption, and an altered dermal environment in which the infection developed. Significantly, this is the first case report of fusariosis in a previously irradiated site of an immunocompromised patient. Treatment included debridement and voriconazole.
