UPMC Dermatopathology "Case of the Month" Presentations
UPP - Department of Dermatology, Dermatopathology Unit
Justin Haught, MD; Arash Radfar, MD; Timothy Patton, DO
MAY 2007 CASE OF THE MONTH
CLINICAL FINDINGS
WB was a 53 year-old white male who presented three weeks after a coronary artery bypass procedure with fevers and a skin rash. During his previous surgery he received 4 units of packed red blood cells and an unknown quantity of other blood products. He was discharged 5 days after the bypass without complication and was doing well. Approximately 5 days prior to presentation he developed fevers, chills, myalgias, malaise, diarrhea, and a red rash limited to his trunk. He also complained of diffuse oral ulcerations and pain with eating. He had no history of medication allergies and his past medical history was significant for coronary artery disease, hypertension, and hyperlipidemia.
On physical exam the temperature was noted to be 39 degrees Celsius. He was alert and oriented. Erythematous patches were noted over his neck, chest (Figure 1), upper abdomen, and back (Figure 2). Nikolsky’s sign was positive. Multiple flaccid bullae were also noted on his back and in his axillae bilaterally (Figure 3). Diffuse erosions on the oral mucosa were present with hemorrhagic crusting throughout the oral cavity (Figure 4). The palpebral conjunctivae were erythematous bilaterally. Blood was noted at the urethral meatus, and he complained of profuse diarrhea with fecal incontinence. The patient died approximately 18 hours after presentation.
Frozen section of blister roof: Full-thickness epidermal necrosis (Figure 5). Hematoxylin/Eosin Stain: Prominent lymphocytic interface dermatitis with Civatte bodies, satellite-cell necrosis, and basilar vacuolopathy. This is consistent with TEN, erythema multiforme major, and graft-versus-host disease (Figures 6, 7, and 8).
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