A 45-year-old woman presented with pruritic, multiple, tense vesicles and confluent erythematous papules and plaques on the trunk, inguinal areas, and upper thighs for 3 days (Fig. 1A-C). She had been diagnosed with stomach cancer (stage T4N0M];) and accompanying carcinomatosis peritonei and had received palliative total gastrectomy with segmental resection of the transverse colon in May 2004. Afterwards, she underwent 4 cycles of taxotere- cisplatin chemotherapy to alleviate some of her symptoms and is currently taking oral 5-fluorouracil as maintenance therapy. Due to the carcinomatosis, both of her ureters were invaded by the cancer cells, which subsequently led to hydronephrosis and persistent urinary tract infection of both kidneys. This was treated by the insertion of double J catheters but the procedure also induced a chronic bacteriuric state.
The patient visited the emergency room in April 2006 with chief complaint of fever and chilling. Laboratory examinations showed a white blood cell count of 14,300/mm2, with 84% segmented neutro- phils, and an elevated blood urea nitrogen and creatinine level (26.8 mg/ml/3.79 mg/ml). The initial urinalysis showed pyuria and hematuria. This, combined with the patient’s symptoms of fever, prompted urine and blood culture. The urine culture showed growth of vancomycin susceptible entero- coccus and treatment was initiated with intravenous vancomycin (2,000 mg/day for 5 days) for the bacteremia. The blood culture revealed growth of Candida albicans, which was subsequently treated with oral fluconazole (200 mg/day for 14 days). On the 13th day after the initiation of vancomycin, but prior to the fluconazole injection, pruritic, multiple, tense vesicles with an erythematous base and confluent erythematous papules and plaques suddenly appeared on the trunk, inguinal areas, and upper thighs. An Asboe-Hansen sign was absent (Fig. 1D) and there was no mucosal involvement. Two biopsy specimens were obtained; one from one of the representative vesicles on the trunk, and the other from the perilesional normal skin. The hematoxylin & eosin stain of the vesicle showed a subepidermal blister, and the blister cavity was filled with inflammatory cell infiltrates, which upon close examination mostly consisted of neutrophils, with a small number of lymphocytes and eosinophils as well (Fig. 2A, B). Direct immunofluorescence microscopy of the specimen taken from perilesional normal skin demonstrated linear deposits of IgA along the basement membrane zone (Fig. 2C). Indirect im- munofluorescence microscopy was negative.
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Fig. 1. Pruritic, multiple, tense vesicles and confluent erythematous papules and plaques on the trunk (A, B) inguinal areas, and upper thighs (C). The Asboe-Hansen sign was negative on palpation (D).
Fig. 2. The biopsy specimen taken from a vesicle on the patient’s trunk shows a subepidermal blister, filled witl an inflammatory cell infiltrate consisting of neutrophils, a small number of lymphocytes, and eosinophils. Direc immunofluorescence microscopy of the specimen taken from perilesional normal skin demonstrates linear deposit of IgA along the basement membrane zone (H&E, A, C: x100, B: x400).
Upon the appearance of the skin lesions, vancomycin was singled out as the possible cause, and was subsequently discontinued. After discontinuation, the skin lesions completely resolved over a period of 2 weeks and no recurrence has been reported in the 6 months following resolution. No additional modalities of treatment were required. Based on these clinicopathological findings, the patient was conclusively diagnosed with vancomycin-induced LABD. She was advised not to use vancomycin again in the future to prevent further recurrences.
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