Bullae and Atypical Target Lesions in a Young Woman

Abstract

A 22-year-old woman with a history of systemic lupus erythematosus was readmitted with fever and a generalized eruption. Six days prior to this admission, she had been hospitalized for a photo-induced flare of acute cutaneous lupus erythematosus (ACLE). At readmission, she was febrile with a temperature of 101.5°F, and on examination, she had a worsening, exquisitely tender rash with several blisters across her right arm. Physical examination revealed erythematous plaques with superficial desquamation in the malar distribution of the face, nose, ears, and medial forehead (Figure, A), as well as bilateral extensor arms, chest, posterior neck, and upper back. Several large bullae were located on the right arm (Figure, B). Numerous flat and raised 2-zoned atypical targets with dusky centers were appreciated on the forearms, abdomen, back (Figure, C), thighs, legs, palms and soles.Hemogram test results revealed a normocytic anemia (mean corpuscular volume, 99 fL; hemoglobin, 11.7 g/dL [to convert to g/L, multiply by 10.0]; hematocrit, 33.4%), in addition to thrombocytopenia (platelet count, 81 K/μL). Other pertinent laboratories included hypocomplementemia (C3 of 42 mg/dL; C4 of 3 mg/dL), a speckled antinuclear antibody titer of 1:1280, and an antidouble-stranded DNA titer of 1:80, along with positive anti-Smith, antiribonucleoprotein, and SSA/anti-Ro antibodies. Bacterial blood, urine, stool and cerebrospinal fluid cultures, and a hepatitis panel revealed no infectious source. Punch biopsy of an abdominal atypical target lesion was performed (Figure , D).