A 25-year-old grand multipara, housewife, Eritrean woman came to a community hospital in the Gash-Barka region of Eritrea, on the 8th of December 2018. During admission the patient complained of amenorrhea that had lasted for four months. She denied a history of taking any herbal/conventional medicine, a previous miscarriage and recent travel to neighboring countries. The patient reported no previous episodes of a similar nature, no past history of medical, surgical and drug allergy. On physical examination, she had pink conjunctiva and anicteric sclera with lesions in oral mucosa. Chest was clear to auscultation and S1/S2 were well heard without murmur or gallop rhythm. The tip of the uterus was palpable, abdominally, at 12 weeks. On vaginal examination, the cervix was closed and the uterus was bimanually palpable without adnexal masses. She had no history of skin rash/lesion or discoloration while visiting the outpatient department. She was investigated with complete blood count, blood group, and urine analysis and imaging. Her complete blood count showed: White blood cell (WBC) 7.2x103, hemoglobin (Hgb) 12.3 g/dl, hematocrit (HCT) 38.2 and platelet count 356 x103 /microL, and urine analysis was normal. Pregnancy test with human chorionic gonadotropin (HCG) dipstick was positive. Trans-abdominal ultrasonography evaluation showed 12 weeks gestation by crown rump length, with absent fetal heartbeat by different sonographers (Figure 1). 
After thorough discussion with the patient and her husband, a decision was reached for immediate admission to the hospital as a case of missed abortion for termination of pregnancy. The patient then took three doses of intravaginal misoprostol 200 mcg tablets in four hour intervals. Following the third dose of misoprostol tablet, the patient developed a diffused itching and burning sensation all over her body, shivering, abdominal cramps and scanty vaginal bleeding.
On physical examination, the patient was acutely sick looking but well orientated to time, person and place. She was hemodynamically stable with vital signs of blood pressure 110/70 mmHg on right arm in supine position, pulse rate 96 beats/minute right radial artery, temperature 38.4  C in left axilla and respiratory rate 20 breaths/minute. On vaginal examination, the cervix was closed with blood on the examining finger. On December 10, 2018, misoprostol was discontinued and oral chlorpheniramine started to treat the itching and burning sensation. On December 11, patient developed a generalized maculopapular skin rash that started at her neck and expanded to nearly all the skin surface including buccal mucosa (Figure 2). The oral cavity revealed several ulcers mainly affecting the sublingual area without extension into the pharynx. The lesions were very painful which prevented her from taking regular meals. 
At the beginning, the skin rash was diffuse erythematous, maculopapular, non-blanching affecting the trunk, bilateral upper and lower limbs, face, and neck. The lesions had a dark red area surrounded by a paler pink zone. The ulceration was more severe on the trunk and lower back without blistering and evidence of superimposed cellulitis (Figure 3). There was no sign of meningitis or facial deviation. Ophthalmological examination revealed no sign of conjunctivas involvement. Due to limitations of laboratory setups, skin biopsy could not be performed. At first, Steven Johnson syndrome was entertained but, later, as the lesions become extensive and covered more than 40% body surface with mucosal involvement, the case was diagnosed as TEN. 
The patient was managed with hydrocortisone 100 mg intravenously four times daily, normal saline 0.9% infusion, ibuprofen 400 mg tablets three times daily, and chlorphenamine maleate tablet 4 mg three times daily. Ampicillin 1 gram intravenously every six hours was also started as prophylaxis because the skin barrier was broken and the hospital environment was prone for nosocomial infection. he patient was also isolated in a separate and relatively clean room to prevent nosocomial infection. Following hydrocortisone injection, the patient reported marked reduction in pruritus without improvement to the skin lesion, which progressed over the next two days that involved all extremities and partly her face. After four days of treatment with hydrocortisone, it was shifted to prednisolone tablet 30 mg, twice daily.
A week after her admission, December 15, 2018, the mother spontaneously expelled the fetus and the remnant was cleared by evacuation with curettage. After 12 days of hospitalization, the patient was discharged with tapered doses of prednisolone tablet. The patient fully recovered gradually, over a four-week period, without sequelae (Figure 4). Finally, the patient consented for her anonymized details and images to be published in an international journal. Ethical approval for publishing case reports was not required by the Ministry of Health of the State of Eritrea.