A 73-year-old man presented with a 1-week history of rash, which first appeared on the trunk and then spread to the face and upper extremities ( and ). Two days later, the rash symmetrically involved the lower extremities () and fever and chills began. He complained of shortness of breath with mild, nonproductive cough. He was anxious and dyspneic upon presentation. He denied any weight loss, night sweats, headache, abdominal pain, chest pain, or urinary symptoms. He had a history of hypertension, coronary artery syndrome, dyslipidemia, and had received coronary artery bypass surgery 3 years before. The patient was a heavy smoker (50 pack-years), drank alcohol socially, and had no history of illicit drug use. His medications included aspirin 75 mg per day, atenolol 50 mg per day, simvastatin 40 mg per day, and bezafibrate (a fibric-acid derivative available in Europe) 200 mg three times per day, which had been started 5 years prior. Allopurinol for hyperuricemia at 300 mg per day was started 1 month prior to presentation.
Scaling of the diffuse confluent erythema all over the patient’s face.
Macular lesions all over the trunk.
Spreading of the rash symmetrically to the lower extremities, purpuric type.
The patient was born in the USA and had immigrated to England during childhood. On presentation, he was in the USA visiting family. He was married and in a monogamous relationship with his wife. He was retired and did not own any pets nor was he aware of any tick or flea bites. There was no history of asthma or rash, nor any known allergies.
On examination, his heart rate was 90 beats/minute, respiratory rate 20 breaths/minute, blood pressure 150/70 mmHg, temperature 38.5°C, SpO2 90% on room air and 96% on 2 L/minute nasal cannula oxygen. He had periorbital edema; a scaling, confluent erythematous rash all over his face; scleral erythema; and crusting of the lips. A macular rash covered the trunk and upper extremities, slightly involved the palms, spared the scalp, and became more confluent and purpuric over the lower extremities (sparing the soles). There were bilateral wheezing and crackles in both lower lung fields. Meningeal signs were absent. The remainder of the examination was normal. Laboratory data included white blood cell count of 8500/*109/L with 68% neutrophils and 12% eosinophils, alanine transaminase 210 U/L, aspartate aminotransferase 165 U/L, blood urea nitrogen 19 mg/dL, and creatinine 1.7 mg/dL. Chest X-ray showed bilateral interstitial infiltrates with left lower lobe atelectasis (). Urine analysis was normal.
Chest X-ray: left lower lobe atelectasis with bilateral interstitial infiltrates.
The patient was admitted to a regular ward for pneumonia treatment and started on ceftriaxone 2 g intravenous once daily and levofloxacine 750 mg intravenous once daily. On the second day, sputum Gram stain showed squamous epithelial cells and a fungal wet preparation showed no organisms. The patient continued to be febrile for the next 2 days, and became confused with increased shortness of breath and more wheezing and crackles on chest exam. Cultures of the blood and urine were sterile. A urine test for Legionella antigen and a serum test for antibodies to Legionella pneumophilia were negative. Salmonella antigen, Brucella-blocking antibodies, viral hepatitis panel (hepatitis A, hepatitis B, hepatitis C), and Epstein–Barr virus immunoglobulin levels were all normal; Weil–Felix test for rickettsia was negative. Stool for parasites was negative. Immunoglobulin E level was also normal.
The allopurinol was stopped and he was started on methylprednisolone 60 mg intravenous every 8 hours. Two days later, the patient became afebrile, the dyspnea resolved, the rash improved significantly, and there was complete resolution of the kidney and hepatic injury. The eosinophil count also returned to a normal value after 5 days ().