case_images: PMC7790587_01
case_images: 8 months prior to admission: hyperkeratotic plaque and erosions.
case_images: CRIDM2020-6695342.001.jpg
case_images: PMC7790587_01_CRIDM2020-6695342.001.jpg
case_images: fig1
case_images: A 67-year-old male had presented to Dermatology OPD of our hospital 8 months back with a history of oral erosions for 2 months and cutaneous erosions for 1 month and was diagnosed as pemphigus vulgaris (Figure 1).
case_images: Day 1 of admission: extension of erosions despite high-dose oral steroids.
case_images: CRIDM2020-6695342.002.jpg
case_images: PMC7790587_01_CRIDM2020-6695342.002.jpg
case_images: fig2
case_images: However, he failed to show satisfactory improvement (Figure 2), and his swab for bacterial culture and sensitivity revealed Pseudomonas aeruginosa sensitive to piperacillin; hence, he was admitted to the dermatology ward and started on the same antibiotic and intravenous, dexamethasone 8 mg once daily along with skin care.
case_images: Day 20 of admission: improvement of erosions but appearance of haemorrhagic crusts.
case_images: CRIDM2020-6695342.003.jpg
case_images: PMC7790587_01_CRIDM2020-6695342.003.jpg
case_images: fig3
case_images: However, 1 week after initiating steroid dose escalation, the patient developed few monomorphic haemorrhagic crusts on the cheeks overlying the pre-existing lesions (Figure 3), which progressed over the next week to involve bilateral cheeks, malar region, and bridge of the nose with few lesions in the forehead, bilateral ears, and chest.
case_images: Day 23 of admission: extensive haemorrhagic crusts in the face and few in the periphery of erosions in the chest.
case_images: CRIDM2020-6695342.004.jpg
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case_images: fig4
case_images: These lesions were associated with extensive cutaneous pain and myalgia (Figure 4).
case_images: Day 27 of admission: further extension of haemorrhagic crusts.
case_images: CRIDM2020-6695342.005.jpg
case_images: PMC7790587_01_CRIDM2020-6695342.005.jpg
case_images: fig5
case_images: Then, he was immediately started on oral acyclovir 400 mg thrice daily, and dexamethasone was tapered rapidly to 9 mg from 16 mg once daily over a week (Figure 5).
case_images: 90% resolution of lesions within 2 weeks of commencing oral acyclovir.
case_images: CRIDM2020-6695342.006.jpg
case_images: PMC7790587_01_CRIDM2020-6695342.006.jpg
case_images: fig6
case_images: Once there was 90% resolution in the haemorrhagic crust, the patient was discharged on 60 mg prednisolone and oral acyclovir 400 mg thrice daily (Figure 6).
case_images: Almost 100% improvement within 4 weeks of commencing antiviral treatment.
case_images: CRIDM2020-6695342.007.jpg
case_images: PMC7790587_01_CRIDM2020-6695342.007.jpg
case_images: fig7
case_images: Oral acyclovir was continued with the same dose for a total of 4 weeks until almost 100% improvement was achieved (Figure 7).