Differential diagnosis, investigations and treatment
The histopathological investigations approved the diagnosis of TEN (Fig. 3). On day 1, she presented with 38.3C fever and 98% oxygen saturation in room air. Lab tests revealed elevated lactate dehydrogenase (648 units/liter (U/L), normal: 140–280 U/L), C-reactive protein level (52 milligrams/Liter (mg/L), normal: <10 mg/L), aspartate aminotransferase (59 U/L, normal: 10–40 U/L). Polymerized chain reaction (PCR) for COVID-19 was negative.
After sepsis work up and an infectiologist consultation, we started her on IV meropenem and vancomycin. For the TEN treatment she received supportive care and oral cyclosporine 200 mg daily that led to the amelioration of her skin condition within three days. In the fourth day of cyclosporine administration re-epithelialization of lesions began. Despite marked improvement of skin lesions, her temperature rose to 38.8C after five days and she developed orthopnea. Spiral non-contrast chest CT scan was then performed which revealed consolidation in right lower lobe and posterior segment of right upper lobe with air bronchogram sign, most likely due to bacterial pneumonia. Bilateral moderate size pleural effusion was also present compatible with volume overload. The antibiotics was then changed to ceftazidime and colistin according to antibiogram of sputum culture. Cyclosporine was discontinued after 10 days.