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.