case_images: PMC7355349_01
case_images: WBC, CRP, and Cr levels at about 4 months after the start of AZA and trends in PSL and AZA medication doses. Blood test results for the days indicated by the bold arrow are shown in Table 1. AZA: azathioprine; PSL: prednisolone.
case_images: CRIPU2020-8852441.001.jpg
case_images: PMC7355349_01_CRIPU2020-8852441.001.jpg
case_images: fig1
case_images: However, 3 days later, the patient developed a fever of 40.3 C with chills and was urgently admitted to our hospital (Figure 1, (2)). Blood tests and imaging studies showed that neither pneumonia nor vasculitis was likely (Figure 2, Table 1, (2)). The next day, at 15:00, the patient developed a fever of 39.3 C with shivering chills (Figure 1, (3)). On Day 106 (AZA 75 mg day-1), there was no fever but the inflammatory response increased and renal function worsened, as the WBC count (16,410 muL-1), CRP level (31.19 mg dL-1), and Cr level (6.4 mg dL-1) increased (Figure 1, (4), Table 1, (4)).
case_images: Changes in chest CT. Date is the number of days after starting AZA. Day 2: diffuse shading, and a regional infiltrative shadow in the right lower lobe is observed. Day 10: scattered nonregional increases in concentration are the same as before. No apparent exacerbation. Day 55: scattered irregular infiltrative shadows in both peripheral lungs and nondistrictal frosted concentrations are observed. Day 72: distinct infiltrative shadows scattered in the periphery of both lungs, with no significant changes.
case_images: CRIPU2020-8852441.002.jpg
case_images: PMC7355349_01_CRIPU2020-8852441.002.jpg
case_images: fig2
case_images: A chest computed tomography (CT) scan was performed, which showed a worsening right lower lobe infiltration shadow, but could not distinguish between an exacerbation of interstitial pneumonia and infection (Figure 2). However, 3 days later, the patient developed a fever of 40.3 C with chills and was urgently admitted to our hospital (Figure 1, (2)). Blood tests and imaging studies showed that neither pneumonia nor vasculitis was likely (Figure 2, Table 1, (2)). WBC count of 8,330 muL-1 and a CRP level of 0.17 mg dL-1 on Day 71, these counts worsened, to a WBC count of 19,650 muL-1 and a CRP level of 16.19 mg dL-1 in less than 30 hours (Table 1, (3)). We performed a systemic search, which included the respiratory (Figure 2) and urinary tracts, but neither test findings nor urine and blood cultures produced significant evidence of infection.
case_images: (a) There is a rash all over the body, mainly on the back. (b) Mild focal neutrophilic infiltration in the superficial dermis and mild to moderate perivascular lymphocytic infiltration. There are no vasculitis findings. Haematoxylin and eosin stain. 200x.
case_images: CRIPU2020-8852441.003.jpg
case_images: PMC7355349_01_CRIPU2020-8852441.003.jpg
case_images: fig3
case_images: Systemic erythema was observed without mucosal damage (Figure 3(a)). A skin biopsy was performed, and the patient was diagnosed with erythema exudativum multiforme based on mild neutrophil infiltration in the shallow dermis (Figure 3(b)). The next day, at 15:00, the patient developed a fever of 39.3 C with shivering chills (Figure 1, (3)).