A 91-year-old female was admitted to our Emergency Department shortly after having been found lying in the shower at home. The patient had lived by herself up to that point and presented with a medical history of arterial hypertension and spinal arthrosis. She had been taking mefenamic acid and paracetamol, but the latter had been changed to metamizole - a pyrazolone derivative - approximately 3 weeks prior to admission. Taking the patient's history was complicated by her age and dementia, and retrospectively, possibly due to a delirious state. On admission, the patient reported having suffered burns from a stove. She then took a shower where she slipped and fell, and was burnt additionally by the hot water. She denied any other respiratory, gastrointestinal and musculoskeletal complaints. Clinically, she presented with epidermal lysis on both thighs and proximal upper extremities, totaling approximately 7% of the TBSA, which in the context of the reported burning, were interpreted as second-degree burns (fig. 1). A brief debridement and wound dressing was performed. The skin showed no adherence to the underlying tissue and could be stripped off without effort. A slight reddish rash was noted on both breasts and the lower abdomen and was interpreted as a reaction to the bandages. In addition, a contusion on the left hip was diagnosed. The patient denied any abdominal pain. She presented with a distended abdomen, tender to the touch in the left lower quadrant, lacking rebound tenderness.
Laboratory studies showed elevated C-reactive protein of 169 mg/l and leucocytes of 33,100/mul. Moreover, she presented with lymphocytopenia (lymphocyte count 500/mul), renal insufficiency (creatinine 121 mumol/l) and a hypokalemia level of 2.7 mmol/l. She tested positive for a nitrite-positive urinary tract infection. An abdominal CT scan was performed. Free air in the abdominal cavity and signs suggestive of perforated sigmoid diverticulitis were observed (fig. 2). The condition was managed by emergent sigmoid colectomy with colostomy (Hartman's procedure). In the course of intubation and surgery, a rapid progression of the epidermal detachment was noted on the abdomen, spreading to 30-40% of her TBSA. A direct Nikolsky sign could be elicited, and an attempt at an indirect sign was negative. Following surgery, the patient was treated with piperacillin/tazobactam (blood cultures remained negative). Renal function deteriorated progressively. During the following 2 days, further cutaneous vesicles developed, the epidermolysis generalized and the patient became increasingly delirious. After 3 days, she showed signs of apneic breathing, after which we decided on palliative treatment. The patient passed away 3 days after admission.