Clindamycin induced toxic epidermal necrolysis versus Staphy
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A 63-year-old male presented with a 2-day history of a widespread, erythematous rash covering all surfaces of his body. The rash appeared 2 days prior to admission with associated prodromal malaise and anorexia. His medical history was significant for a cellulitis of his left lower limb for which he was prescribed oral clindamycin 5 days prior. On presentation he was apyrexic, tachycardic and was tachypneoic. He was normotensive (126/84 mmHg) and remained alert and interactive clinical examination was remarkable for an oatmeal dermatitis of the face and perioral area and an erythematous, blistering rash covering 80% of his total body surface area. Nikolosky sign was positive. Oral involvement was noted. The palms of his hands and the soles of his feet were spared.

Potentially causative medications (including clindamycin) were stopped. Electrocardiogram confirmed atrial fibrillation. The patient was immediately isolated from other patients and increased contact precautions were taken. Fluid resuscitation was commenced as per local hospital sepsis guidelines and urinary output monitored. Paraffin gel was applied liberally two hourly and potent topical corticosteroids twice daily. Intravenous hydrocortisone (100 mg) was given four times daily. Repetitive swab cultures from blister sites and blood cultures were negative for Staphylococcus infection rendering SSSS diagnosis less likely.

This case demonstrates a favourable outcome despite ambiguity in suspected dermatological disease processes and disparate histology. Staphylococcal scalded skin and toxic epidermal necrolysis are known to clinically present in an almost analogous manner despite disparate disease processes and can pose diagnostic difficulty as clearly outlined in this case where a patient does not clearly fit into either disease process.

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