case_images: PMC11760121_01
case_images: Summary of the patient's medical history.
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case_images: Figure 1 displays the chronology of the disease.
case_images: Desquamation occurred on the forehead, cheeks, and nasolabial region, accompanied by edema on the face, especially on the lips, where erosive areas were also covered by crusts (a, b). Desquamation, along with residual hyperpigmentation, was observed on the extremities and abdomen (c, d).
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case_images: By the sixth day, she exhibited desquamation, pruritus, edema of the lips and eyelids, and painful ulcerative lesions in the mouth, accompanied by dysphonia, dysphagia, and respiratory failure (pH: 7.36; pCO2: 44 mmHg; PO2: 58 mmHg; PaO2/FiO2 ratio: 276), requiring the placement of a nasogastric tube and the use of supplemental oxygen (FiO2: 36%; Figure 2).
case_images: Depicts a skin biopsy (H&E staining). Orthokeratosis and the epidermis exhibited signs of sudden necrosis, associated with multiple apoptotic keratinocytes (black arrow). The dermis showed a mild inflammatory infiltrate, composed of lymphocytes and eosinophils, along with scattered foci of melanin pigment (white arrow).
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case_images: Considering a score of 11 points on the RegiSCAR classification system, the patient's clinical features, a 9-point evaluation on the Algorithm for Drug Causality for Epidermal Necrolysis (ALDEN; Supplemental Table S1), and the histopathological findings from the skin biopsy, which revealed orthohyperkeratosis and evidence of confluent apoptotic necrosis of keratinocytes in the epidermis, along with a perivascular infiltrate in the dermis consisting of lymphocytes, histiocytes, and some eosinophils, as well as red blood cell extravasation, interstitial edema, and foci of melanocytic pigment (Figure 3), it was concluded that this is a case of DRESS/SJS overlap.
case_images: It showed the total recovery of the cutaneous lesions on the face attributed to the DRESS/SJS superimposition (a). Grade II-1 alopecia was observed according to the Ludwig scale, affecting the crown region and extending toward the left side of the occipital region (b).. DRESS, Drug Reaction with Eosinophilia and Systemic Symptoms; SJS, Stevens-Johnson syndrome.
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case_images: Follow-up showed that the skin lesions had resolved, and she had good tolerance to the treatment, although she had developed progressive alopecia (Figure 4), which led to her being referred to dermatology for evaluation.