A 26-year-old young female with end-stage renal disease due to focal segmental glomerulosclerosis on maintenance hemodialysis was admitted for malignant hypertension to our Nephrology department. She was known to have tuberculous lymphadenitis and was on antituberculosis therapy for the preceding 4 months. On the day of admission, she had an episode of generalized tonic clonic seizures for which she was given 1 gram of phenytoin intravenously as loading dose and was continued on 300 mg PO daily. After 2 weeks, she was noted to have neutropenia (Absolute neutrophil count- <1000/mm3). She was evaluated for neutropenia and filgrastim 300 mcg was injected subcutaneously. Within a few hours of injection she reported itching around the site of injection and swelling of eyes, facial swelling, and itchy red rashes over the lips, face, upper and lower back [Figure 1]. Erythematous papules over legs, hands and several bullae and purpuric lesions over the palm, sole and feet were observed [Figure 2]. She developed desquamation of skin involving >80% of the skin surface and mucosa. There was no involvement of the eyes. So both phenytoin and filgrastim were withdrawn immediately. A skin biopsy was performed, which showed ulcerated epidermis with necrotic keratinocytes with acrosyringeal extension and few eosinophils overlying focally necrotic and edematous papillary dermis with neutrophil and lymphocytic infiltrate, melanin drop out along with perivascular lymphocytosis and adnexal structures. Subepidermal bulla was seen with focal in growth of epidermis [Figure 3]. It was suggestive of TEN.
The patient was shifted to ICU and was treated with intravenous immunoglobulin (IVIG) 2 g/kg over 5 days and steroids with prophylactic antibiotics. Daily dressing was performed. She was continued on hemodialysis during the hospital stay and gradually her skin lesions improved significantly [Figure 4]. Presently she is doing well and is on maintenance hemodialysis.