Derma Case: 52-year-old Man with Fever, Muscle Aches, and Rash

00:01 So next up, we're going to talk adverse cutaneous drug reactions and related skin disorders.

00:08 Let's go into a case. So this is a 52-year-old man with a history of gout and HIV. He has a CD4 count of 418 and an undetectable viral load.

00:17 And he's on dolutegravir, tenofovir, and emtricitabine for the past 9 months. He's now presenting with fevers, muscle aches, and a rash. Now, the fevers and myalgias began about 2 days ago, and then he noticed a rash on his face and his chest when he was going to bed last night. This morning, he noted his skin was tender to the touch, and he also reports his throat is sore.

00:39 He also reports that he started taking allopurinol for recurrent gout about 9 days ago. Non-smoker, no alcohol, no illicit drugs. Family history is non-contributory, and on review of systems, he describes no dyspnea, but he says his eyes are burning. Denies any blurred vision.

00:57 No joint pain, no nausea, dysuria, cough, or headache.

01:01 So, let's take a look at a few key points about this case, thus far.

01:04 First off, the time course. It sounds like his symptoms have really begun over just the past 2 days, so I would consider this to be an acute presentation.

01:13 In terms of a pattern of skin involvement, at least based on what we know thus far, he's describing it on his face and his chest.

01:18 We'll see if it's symmetric on the next physical exam.

01:22 Skin inflammation appears to be present and so far, as he says, his skin is tender to the touch.

01:27 And lastly, systemic involvement. Well, we're hearing about fevers, muscle aches, a sore throat, burning eyes.

01:34 It sounds like something systemic is happening here.

01:36 It's not just a cutaneous problem.

01:39 All right. So, let's get that physical exam. Temperature, he's got a 38.3°C temperature, his heart rate's 92, blood pressure looks okay. On head and neck exam, he has bilateral, conjunctival injection with blepharedema, no lymphadenopathy.

01:54 Cardiopulmonary exam, he's got a regular rate and rhythm, no murmurs, his lungs are clear, and his abdomen is benign, as well.

02:01 Now, looking at his skin exam, He has a positive Nikolsky sign, and his skin is tender to palpation, as he described.

02:08 And on the skin exam, we see perioral erosions and edema at the vermilion border with grayish-white exudates.

02:15 There are ill-defined symmetric erythema of the central face and torso that's spreading to the proximal limbs, sparing the palms and soles, covering 40% of the total body surface, with scattered areas of 'crinkled'- appearing skin and early bullae.

02:31 His Nikolsky sign is positive, and his skin is tender to palpation.

02:36 All right. So, based on that history and physical, which of the following is the most likely diagnosis? Well, since the first 3 on this list are all cutaneous drug reactions, let's just take a look at the 2 at the bottom first.