A rapidly progressive rash with mucosal involvement

A 40-year-old man, recently diagnosed with systemic lupus erythematosus, presented to the emergency department with a one-week history of high fever, headache, cough, and keratoconjunctivitis. Two weeks earlier, he had started treatment with hydroxychloroquine 200 mg twice daily (400 mg/day orally). After the onset of fever, he self-administered paracetamol 1 g three times daily. Within 48 hours, a rapid worsening of pre-existing cutaneous lesions occurred. Macular lesions rapidly coalesced into large flaccid blisters involving the face, chest, palms, and soles. The lesions exfoliated within three days. The patient reported severe pain affecting the skin and the mucous membranes of the mouth, genitals, and eyes. A positive Nikolsky sign was observed. On admission, he was febrile (38.5°C), with blood pressure 100/70 mmHg, heart rate 100 bpm, and respiratory rate 25 breaths per minute. Cutaneous detachment with areas of necrosis involved approximately 8% of the body surface area, predominantly involving the extremities, particularly the hands. Within a few days, all the lesions became necrotic. Laboratory tests showed leukocytosis and elevated C-reactive protein, while procalcitonin was negative. Pain severity was rated 9/10 on a visual analogue scale, requiring intravenous tramadol 100 mg every 8 hours for analgesia.