Publication:

Toxic epidermal necrolysis like acute cutaneous lupus erythematous or drug induced toxic epidermal necrolysis: case report of a diagnostic dilemma

Systemic lupus erythematosus (SLE) is an autoimmune disorder causing microvascular inflammation with generation of antinuclear auto-antibodies. It can have varied presentations and its coexistence with other disorders makes diagnosis and management all the more challenging. We describe a young male, known case of SLE and pulmonary tuberculosis on anti-tubercular treatment presenting with sudden onset diffuse maculopapular dusky rash, oral lesions, fever, joint pain and photosensitivity. Positive Nikolsky’s sign on clinical examination, epidermal necrosis on histopathology, negative direct immunofluorescence and Naranjo’s causality assessment clinched the diagnosis of streptomycin-induced toxic epidermal necrolysis (TEN) in SLE. Rash responded rapidly to systemic steroids and discontinuation of anti-tubercular drugs. Rifampicin, ethambutol and isoniazid have been previously incriminated in TEN but streptomycin- induced toxic epidermal necrolysis remains an extremely rare event. TEN like rash of lupus is a rare entity clinically indistinguishable from drug induced TEN. Moreover, TEN is known to occur with increased frequency in connective tissue disorders.