Case presentation

We present the case of a 69-year-old man who had been diagnosed with insulin-dependent diabetes and hypertension 15 years earlier. He was receiving insulin for diabetes management and the combination medication Exforge (amlodipine/valsartan) for hypertension control. The patient was admitted with a scarlet fever-like rash accompanied by skin detachment.

Investigations revealed that he had been taking celecoxib for six days, following a medical prescription, to treat arthralgia. The patient was subsequently admitted to the Dermatology Department, where he was hospitalized for seven days.

On admission, the patient was conscious, hemodynamically and respiratorily stable, with a BP of 130/70 mmHg, morbilliform erythroderma, and skin detachment involving <10% of the body surface area. Laboratory investigations showed the following: WBC, 9,500/mm³; urea, 1.44 g/L; creatinine, 21.1 mg/L; K+, 4.5 mmol/L; Na+, 128 mmol/L; sterile cytobacteriological examination of urine (CBEU); and no hepatic cytolysis. Therapeutic measures included celecoxib discontinuation, daily wound dressings, antibiotic therapy with amoxicillin/clavulanic acid, and thromboprophylaxis.

The following changes occurred seven days later: clinical worsening, disturbance of consciousness (Glasgow Coma Score (GCS) not specified), and biological deterioration, including impaired renal function (creatinine, 76 mg/L; urea, 2.48 g/L) and abnormal liver function tests (cytolysis and cholestasis: aspartate transaminase (ASAT), 2.5×N; alanine transaminase (ALAT), 2×N; gamma-glutamyl transferase (GGT), 8.8×N).

Given the clinical and biological deterioration, he was transferred to our Intensive Care Unit (ICU) for management.

Clinical examination on admission to our unit revealed an unconscious patient with a GCS of 11-12/15, BP of 80/40 mmHg, heart rate of 125 bpm, and SpO₂ of 91% on room air. A scarlatiniform exanthema covered 80% of the integument, with skin detachment involving 40% of the body surface area and a characteristic moist, denuded dermis (Figures 1-3). Oral enanthema and bilateral conjunctivitis with yellowish secretions were also present. The patient had an ALDEN score of 4 and a SCORTEN of 5.

Figure 1: Lesions on the frontal part of the trunk

Figure 2: Characteristic moist denuded dermis with skin detachment from the gluteal region and upper thigh

Figure 3: Characteristic moist denuded dermis of the back

Biological tests revealed the following abnormalities (Table 1): albumin, 17 g/L; CRP, 294.71 mg/L; procalcitonin, 21.27 ng/L; lactate dehydrogenase (LDH), 302 IU/L; and lymphocytes, 670/µL.

Variable | Patient Results | Normal Value
Albumin | 17 g/L | 35 - 50 g/L
CRP | 294.71 mg/L | 0 - 5 mg/L
Urea | 2.51 g/L | 0.15 - 0.45 g/L
Creatinine | 82.96 mg/L | 7.2 - 12.5 mg/L
LDH | 302 IU/L | 125 - 243 IU/L
Procalcitonin | 21.27 ng/L | < 0.1 ng/L
Hemoglobin | 9.7 g/dL | 12 - 18 g/dL
WBC | 7340/µL | 4000 - 10000/µL
Platelets | 193000/µL | 150000 - 400000/µL
Lymphocytes | 670/µL | 1000 - 4000/µL
ASAT | 74 IU/L | 5 - 34 IU/L
ALAT | 58 IU/L | 0 - 55 IU/L

Arterial blood gas (ABG) analysis showed the following (Table 2): pH, 7.39; PaO₂, 69 mmHg; PaCO₂, 30.5 mmHg; SaO₂, 94%; HCO₃⁻, 13.9 mmol/L; lactate, 3 mmol/L.

Variable | Patient Results | Normal Values
pH | 7.39 | 7.35 - 7.45
PaO₂ | 69 mmHg | 75 - 100 mmHg
PCO2 | 30.5 mmHg | 35 - 45 mmHg
SaO₂ | 94% | >95%
O2(L/min) | AA | AA
HCO₃⁻ | 13.9 mmol/L | 22 - 26 mmol/L
Lactate | 3 mmol/L | < 2 mmol/L

The skin swab was sterile, and no biopsy was performed. The patient underwent a non-contrast CT scan of the thorax, which revealed bilateral infectious pneumonitis (Figure 4).

Figure 4: Cross-sectional image through the lung bases showing minimal bilateral basal pneumonia (red arrows)

He was treated with rehydration according to Brooke's regimen, vasoactive drugs, antibiotics, albumin, oxygen therapy via nasal cannulas, daily wound dressing changes, a protein-rich diet, plasma exchange, and eye care. The outcome was unfavorable, and the patient died 48 hours after admission to the ICU.