Past medical history was significant for hypertension, gout, non-insulin dependent adult onset diabetes, and squamous cell carcinoma of the lung with metastases to the brain. The patient had completed chemotherapy and was still undergoing radiation therapy to the cranium.

Chronic medications included allopurinol, lisinopril, glyburide, acarbose, and metformin. Recently added medications included dexamethasone which had been started several weeks ago due to cerebral edema, and cabamazepine which had been started six weeks previously for seizure prophylaxis. The patient had previously been on phenytoin for seizure prophylaxis, but this was discontinued at the time the carbamazepine was started.

Examination revealed temperature 37.5 C, pulse 108, respirations 16, blood pressure 120/70. Cutaneous examination revealed dusky, erythematous macules becoming confluent over the chest (Figure 1), back (Figure 2), upper extremities, proximal lower extremities, and palms (Figure 3). Superficial sloughing was easily induced with lateral pressure to involved skin (Figure 4). No target lesions were identified. The lips showed erosions with hemorrhagic crusting (Figure 3), the rest of the oral cavity was uninvolved. Eye examination revealed conjunctival injection, edema, and exudates. Total involvement was estimated at 25-30% of body surface area.

Initial laboratory studies at admission were as follows: Hgb 13.5, Hct 39.6, WBC 6.3, Platelets 292, BUN 17, Creat 0.9, Potassium 4.2, Sodium 128, Bicarbonate 21, Chloride 96, Glucose 320, GGT 638, Alk Phos 153, ALT 70, AST 44.

Two skin biopsies were taken from the mid-upper back. These revealed a pauci-inflammatory specimen with a subepidermal separation between the epidermis and dermis. The most prominent feature of the biopsy was full thickness necrosis of the epidermis (Figure 5, Figure 6). Immunofluorescence studies revealed globular deposition of IgG, IgM, IgA, and C3 (Figure 7).