Bullous eruption due to Cimex lecticularis.

A 14-year-old-girl undergoing treatment with the BFMTRALL 2000 protocol (MRG ) because of early pre-B-cellacute lymphoblastic leukemia (ALL ) developed chickenpox on the 33rd d of remission induction. As such, chemotherapywas withdrawn and the patient was quarantined.Acyclovir (1500 mg·m–2·d–1 in three divided doses)was then administered in 100 mL of 0.9% sodium chloride,as 1-h intravenous infusions. On the 9th d of acyclovirtherapy 10 min after infusion of the 27th dose startedthe patient complained of the sensation of minor pain andburning in the region of Intracath catheter insertion, anddeveloped slight erythema with irregular boundaries inthe same region. The infusion line was checked for patency by gentlywithdrawing blood before, which showed that the linewas patent, and then infusion was continued, but at aslower rate. The line’s patency was checked frequently andremained patent. The patient no longer experienced thesensation of pain and burning, and the erythema improvedslightly; however, at the end of the infusion (the 65th min)a solitary, bullous painless eruption 1 x 1 cm in diameterwas observed on the tract of the vein, 10 cm distal of theIntracath insertion (Figures ​(Figures11,​,22,3,4). Without any medicalintervention the lesion subsided in 8 h and disappearedcompletely in 24 h, leaving behind a residual scar lesion. Figure 1 Cutaneous vesicular eruption on the forearm ofthe patient which developed after acyclovir injection. Figure 2 Cutaneous vesicular eruption on the forearm ofthe patient which developed after acyclovir injection. Figure 3 Cutaneous vesicular eruption on the forearm ofthe patient which developed after acyclovir injection. The known adverse dermatological effects of acyclovir,including erythema, inflammation, and phlebitis at the siteof intravenous infusion, occur in ≤16% of patients, presumablydue to the alkaline nature of the solution (reconstitutedacyclovir has a pH of 10-11) [1]. It is a knownirritant to venous and soft tissue if extravasated [2].Wethink that both the erythema and bullous eruption inthe presented case were signs of subcutaneous acyclovirextravasation, despite the fact that we frequently checkedthe line and were confident of its patency. Frequent venipuncture of the same veins and use ofchemotherapeutic agents in oncology patients may rendertheir veins fragile and susceptible to the irritant effects ofdrugs. As such, sensation of pain and burning in oncologypatients should be considered a reliable sign of extravasationeven when good blood return is observed. Nonetheless,cutaneous vesicular eruption following intravenousacyclovir administration is rare [1]. It was reported thatcutaneous vesicular eruptions developed not only at thesite of injection, but far from it [3] and proximal to it [1].Moreover, bullous eruptions were also reported followingtopical and oral acyclovir administration [1]; therefore,rather than extravasation of acyclovir solution, an immunoallergicpattern in the presence of histological leukocytoclasticvasculitis is an etiological consideration [3]. The presented case shows that the irritant effects ofacyclovir should always be a consideration, especially inoncology patients, and that the development of new vesiculareruptions during acyclovir therapy should not alwaysbe considered progression of herpes infection. Conflict of Interest Statement The authors of this paper have no conflicts of interest,including specific financial interests, relationships, and/or affiliations relevant to the subject matter or materialsincluded. Acknowledgement I thank Lale Olcay, MD for kindly revising the manuscript.

IntroductionWith the approval of the adjuvanted recombinant zoster vaccine (RZV; Shingrix, GSK) in October 2017, GSK established enhanced safety surveillance measures to allow prompt identification of potential safety signals not observed during clinical development. In Germany, cases of vesicular and bullous cutaneous eruptions following RZV vaccination were reported.ObjectiveOur objective was to search and analyse 2.5 years of worldwide spontaneously reported post-marketing data for vesicular and bullous cutaneous eruptions, represented by adverse events suggestive of (1) herpes zoster (HZ) and (2) non-HZ vesicular and bullous cutaneous eruptions, that occurred following RZV vaccination.MethodsWe conducted a descriptive analysis of all identified reports of HZ and non-HZ vesicular and bullous cutaneous eruptions following RZV vaccination and an observed versus expected (O/E) analysis of reports of HZ that met criteria of varicella zoster virus (VZV) reactivations following RZV vaccination (i.e., time to onset [TTO] of the event < 30 days or missing after any dose).ResultsUntil the data lock point, 32,597,779 RZV doses had been distributed globally. There were 2423 reports of HZ (including complications) identified, of which 645 met the criteria of possible vaccination failure (i.e., TTO of the event ≥ 30 days or missing following a complete RZV vaccination schedule). The O/E analysis of 1928 reports assessed as possible VZV reactivations indicated that the observed number of cases was lower than that expected in the general population. Additionally, 810 reports of non-HZ vesicular and bullous cutaneous eruptions were identified, including injection site rashes attributed to the vaccine’s reactogenicity.ConclusionThis review of spontaneously reported post-marketing data did not raise safety concerns regarding the occurrence of vesicular and bullous cutaneous eruptions following vaccination with RZV.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40264-021-01118-3.

Congenital syphilis occurs when Treponema pallidum crosses the placenta during pregnancy or from contact with an infectious genital lesion during delivery. Cutaneous manifestations of congenital syphilis are relatively common, occurring in approximately 30% to 70% of patients. Maculopapular lesions, vesiculobullous lesions, condylomata lata lesions, annular lesions, and erythema multiforme-like targetoid lesions have been reported. We report on a premature newborn with congenital syphilis who presented with generalized bullous and pustular eruption and desquamation at birth.

Enoxaparin sodium–induced bullous pemphigoid-like eruption: a report of 2 cases

Severe bullous skin eruptions on checkpoint inhibitor therapy - in most cases severe bullous lichenoid drug eruptions.

Metronidazole is a synthetic nitroimidazole drug indicated in trichomoniasis, amebiasis, giardiasis and anaerobic and mixed bacterial infections. The common side effects due to this drug include GI disturbances, weakness, dizziness, ataxia, headache, drowsiness, insomnia, maculopapular skin eruptions, urticaria, pruritus, and occasionally erythema multiforme. We hereby report a case of bullous drug eruption due to metronidazole with an established causality, severity, preventability and predictability in a 99 year old male. Patient gave history of three days treatment with Inj. Metronidazole following which he developed severe generalized itching within one day of the above treatment and noticed the blisters on the second day. A diagnosis of metronidazole induced bullous eruption was made, and the patient was managed with Tab. Prednisolone 30mg/day tapered over 10 days, along with Tab Ranitidine, tab Fexofenadine, tab Cetrizine, Gentian violet paint and Fusidic acid+Betamethasone cream.

BackgroundIgA pemphigus is a rare autoimmune vesiculo-pustular skin disease. Only approximately 70 cases have been reported to date. We report a case of IgA pemphigus with IgA antibodies to desmoglein 1 (Dsg1) and desmoglein 3 (Dsg3).Case reportWe report the case of an 60-year-old man with intraepidermal neutrophilic IgA pemphigus with IgA antibodies to Dsg1 and Dsg3. Histologic examination revealed subcorneal neutrophilic pustules with few acantholytic cells. The disease was not effectively controlled by conventional therapeutic regimens (colchicine, dapsone). Systemic treatment with isotretinoin 25 mg/d and prednisone 20 mg/d achieved only a slight effect after six months.ConclusionsOur case confirmed the recalcitrant nature of IgA pemphigus in response to distinct therapies, indicating that further research focusing on therapeutic approaches for this type of pemphigus is needed. Physicians should keep IgA pemphigus in mind when approaching patients with bullous eruption.

Toxic epidermal necrolysis (TEN) is a potentially life-threatening muco-cutaneous disease, largely caused by an idiosyncratic reaction to medication or infectious disease, and is characterised by acute necrosis of the epidermis. No definitive consensus regarding the treatment of TEN has been agreed. A 60-year-old woman, diagnosed with multiple myeloma three months prior, was admitted with signs of TEN to the intensive care burns unit. She had been given ciprofloxacin to treat a urinary tract infection. She complained of malaise and pain, with maculopapular and bullous eruptions over her whole body on the third day of ciprofloxacin administration. Her supportive cares included intravenous immunoglobulins, pain control with analgesics, wound care, nutrition, and fluid support. Hyperbaric oxygen treatment (HBOT) was added on the second day of admission. The patient underwent 5 sessions of HBOT at 243.1 kPa (2.4 atmospheres absolute). Desquamation was noted to stop after the first session of HBOT and re-epithelisation commenced rapidly. The patient was discharged from the burn unit after 14 days of hospital admission. Improvement in this case was temporally related to the initiation of HBOT.

A bullous eruption in an elderly woman. Vancomycin-associated linear IgA dermatosis (LAD).

REPORT OF A CASE A 72-year-old woman was hospitalized for a total pelvic exenteration for transitional cell carcinoma of the bladder. Her postoperative course was complicated by multiple infections that were treated with multiple antibiotics, including intravenous amphotericin B, ampicillin, gentamicin, metronidazole, cefoxitin, ceftriaxone, ticarcillin, vancomycin, and oral sulfamethoxazole-trimethoprim. On postoperative days 26 and 27, the patient had temperature spikes to 39°C. Vancomycin therapy was begun (both intravenous and per cecostomy tube) on postoperative day 27 for a presumptive staphylococcal infection. On day 28, a generalized, burning bullous eruption involving the palms, soles, and conjunctivae developed. Medications at the time were intravenous amphotericin B, metronidazole, ceftriaxone, and vancomycin (intravenous and per cecostomy tube); oral sulfamethoxazole-trimethoprim, metoprolol, hydrochlorothiazide, magnesium oxide, oxycodone, acetaminophen, and diphenhydramine; subcutaneous heparin; and topical conjugated estrogen cream. Consultation was obtained on day 2 of the eruption. Physical examination revealed erythematous-to-dusky, occasionally targetoid papules and plaques over the

Dear Editor: Skin manifestations in systemic lupus erythematosus (SLE) are very heterogeneous. Recently, Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN)-like lupus erythematosus (LE) has been reported. Clinically, this condition presents with photodistributed exanthema and minimal mucositis. The onset of the rash is insidious with a prolonged clinical course1. A 16-year-old Korean woman presented with a 4-week history of gradually progressive development of painful, annular, erythematous, flattened, and blistering eruptions. Crusting presented on the face, V-neck area, upper back, and dorsum of the hands, and involved less than 10% of body surface area. The lips had erosions and crusts (Fig. 1). Eye and genital examinations were unremarkable. Previous medical history included malar rash and diffuse alopecia. No relevant medications had been newly administered. Fig. 1 Photodistributed erythematous flattened vesiculobullous eruptions with crusts on the face, V-neck area and the dorsum of hands and erosion on the lips. Skin biopsy from the back revealed a subepidermal blister with exocytosis and superficial perivascular infiltration of lymphocytes and neutrophils. Marked necrosis of keratinocytes of the suprabasal layer and interface dermatitis were manifested (Fig. 2). Direct immunofluorescence microscopy was remarkable in that linear deposits of immunoglobulin G, C3, and C1q were shown at the basement membrane zone. Fig. 2 Subepidermal blister with exocytosis and superficial perivascular infiltration of lymphocytes and neutrophils, marked necrosis of keratinocytes of the suprabasal layer and interface change (H&E, ×100). Laboratory investigations demonstrated anemia (hemoglobin 10.9 g/dl), leukopenia (3,600/mm3), and a normal platelet count. The antinuclear antibody titer was positive (1:640 homogeneous pattern), anti-double-stranded DNA was positive, anti-Ro/SS-A was positive and anti-La/SS-B was negative. Anti-Sm was positive, anti-nucleosome, anti-histones, and rheumatoid factor were negative. C3 and C4 levels were markedly low at 47.2 g/dl and 13.6 g/dl, respectively. Plasma creatinine was 0.65 mg/dl and the 24-hour urine proteinuria was 1,589 mg/day. Lupus nephritis class IIA was diagnosed from kidney biopsy. Liver function tests were unremarkable. Eventually, SJS-like cutaneous presentation with juvenile SLE was diagnosed based on the above findings. Treatment regimen included oral hydroxychloroquine 200 mg, deflazacort 48 mg per day with gradual tapering. Lesions improved after dressing on the denuded area and applying topical corticosteroid. Skin is the second most commonly affected organ system in SLE2. A bullous eruption in the setting of SLE can be a diagnostic challenge. Classic SJS/TEN, SJS/TEN-like LE, drug-induced cutaneous LE, bullous LE, Rowell's syndrome, and immunobullous diseases need to be considered in the differential diagnosis3. Indirect immunofluorescence is an effective method to diagnose bullous LE, but the present patient did not undergo this test. However, bullous LE appears with various-sized tense blisters, which is clinically different from the patient's presentation. Usually, SJS/TEN-like LE develops as a result of severe inflammatory epidermal basal layer damage. Vacuolar degeneration leads to subepidermal blistering and almost full-thickness epidermal necrosis1,4. SJS/TEN-like LE is often triggered by excessive ultraviolet exposure with an underlying predisposition to SLE. These patients often have anti-Ro antibody. Anti-Ro may be associated with increased risk of photosensitive rash4. The standard treatment of SJS/TEN-like LE remains controversial. Corticosteroids were prescribed in the present case because of continuing lupus activity. Chloroquine was combined for immunomodulation. In previous reports of TEN-like acute cutaneous LE, intravenous immunoglobulin, and plasmapheresis were successful5. To our knowledge, SJS-like skin lesions with juvenile SLE have rarely been reported in the literature. This was the first case reported in Korea.

BackgroundTargeted and immune therapies have recently been associated with the occurrence of multiple cutaneous toxicities, often challenging to differentiate by clinical examination alone without histology. Line‐field confocal optical coherence tomography (LC‐OCT) is a non‐invasive and innovative imaging technique that has been shown to be almost as effective as histology in diagnosing several skin conditions. Our study aimed to assess the effectiveness of LC‐OCT in predicting the clinical evolution of early maculopapular eruptions related to antineoplastic targeted therapy and immunotherapy.MethodsIn the period between May 2023 and December 2023, consecutive patients with clinical cutaneous maculopapular reactions caused by oncologic targeted therapy or immunotherapy were enrolled at the dermatologic outpatient clinic of the Fondazione Policlinico A. Gemelli IRCCS, Rome. Patients underwent clinical dermatological examination, video‐dermoscopy, LC‐OCT, and incisional skin biopsy of a target cutaneous lesion. To investigate the evolutionary pattern of maculopapular lesions (psoriasic eruption, lichenoid eruption, eczematous eruption, bullous eruption), LC‐OCT and histopathological images have been compared based on specific characteristics (hyperkeratosis, acanthosis, spongiosis; papillomatosis; lichenoid inflammatory infiltrate; presence of intraepidermal/subepidermal cleavage plan with formation of a bulla).ResultsEighteen patients were included in this study (11 males, 7 females, median age 64.5). LC‐OCT demonstrated an overall concordance with histology of 77.8%, with a Cohen's Kappa of 0.69 (P < 0.0001). Sensitivity exceeded 70%, and specificity was ≥88.2%. The Area Under the Curve (AUC) ranged from 0.9 to 1 for psoriasis and lichenoid eruption and from 0.7 to 0.9 for eczematous and bullous eruption.ConclusionsLC‐OCT appears to be a promising tool for the early differential diagnosis of adverse skin reactions related to targeted therapy and immunotherapy, offering the potential to avoid skin biopsies in fragile cancer patients.

Case Presentation60-year-old male admitted for routine sigmoidectomy secondary to multiple unresectable colonic polyps.Surgery was complicated by significant blood loss, conversion to open

Bullous eruption in a 1-year-old female in the Philippines: A diagnostic challenge

Wells’ syndrome or eosinophilic cellulitis is a rare disease of which bullous form is uncommon, especially in children. We report a rare and original case of bullous Wells’ syndrome in a 10-year-old boy who was successfully treated with oral dapsone. It is therefore important to consider Wells’ syndrome in patients presenting recalcitrant bullous cutaneous eruption with eosinophilia.