Case history / examination
In January 2019 a 42 year old male presented with fever, extensive
widespread skin lesions and painful oral ulcers to the emergency
department of Imam Reza hospital of Mashhad city, Iran.
In physical examination he had a fever of 39°C, multiple ulcers on the
soft palette and tongue, extensive reddish purple papules and plaques on
the face, scalp, torso and limbs. The plaques in some areas were
inflammated and ulcerated with serous discharge and some were
erythematous with thick hyperkeratotic crusts. (Figures 1 and 2) Also
bilateral orbital edema, cushingoid appearance and two atrophic scars on
the right cheek were witnessed.
The lesions had started two years ago and ever since there were periods
of remissions and recurrences. During the last few days the patient had
experienced deterioration of skin lesions and development of oral ulcers
and fever.
There was a history of CL lesions on the face four years ago and he had
undergone treatment with intralesional antimoniate which was followed by
partial remission.
The patient reported arbitrary use of prednisolone 30mg per day due to
Rheumatoid Arthritis (RA) for 10 years.
The patient was febrile and had some punched-out ulcers on his soft
palate causing severe dysphagia alongside extensive and widespread skin
lesions which in some areas were ulcerated with serous discharge
promoting a primary diagnosis of bacteremia status and reactivated HSV
due to immunosuppression. Patient received antibiotics and oral
acyclovir in the emergency department.