In 1996, a 43-year-old Hispanic female was diagnosed and treated for breast cancer. After a recurrence 11 years later, she underwent a bilateral mastectomy in 2007. In January 2008, she complained of a 2-week history of worsening headaches, photophobia, and vertigo. Computed tomography and magnetic resonance imaging showed metastases to the occipital and parietal brain and spine. On February 3, 2008, she was started on palliative cranial irradiation of 45 Gy delivered in 22 fractions at 2 Gy/fraction. At that time, she had the following medications: a tapering dose of dexamethasone (4 mg 4 times daily), phenytoin (100 mg 3 times daily) for seizure prophylaxis, and antacids. Twenty-three days later, she had developed facial swelling and a diffuse maculopapular eruption of the head, scalp, and upper body. She was initially diagnosed with cellulitis and treated with clindamycin (900 mg i.v. 3 times daily) and levofloxacin (750 mg i.v. daily), along with methylprednisolone (125 mg i.v. 4 times daily). Twenty-six days after the start of her radiation therapy, she developed intractable vomiting and blisters, requiring admission for further evaluation. She had completed 3 weeks of cranial irradiation, receiving 32 Gy of a planned 45-Gy regimen. Despite initiation of antibiotics, her facial swelling worsened and blisters progressed to involve her ears. She also experienced odynophagia and dysuria. Phenytoin was discontinued 2 days after admission due to a suspicion of a possible drug reaction. Intravenous fluconazole (200 mg daily) was given for oral candidiasis and enoxaparin for deep-vein thrombosis prophylaxis. On March 5, 2008, she was transferred to the burn center for treatment of TENS. The patient had diffuse erythema and bullae with sloughing of facial and scalp epidermis, bilateral conjunctivitis, xerostomia, and oral mucosal ulceration with sloughing of the hard and soft palate, and dorsal tongue surface. Widespread bullae with a positive Nikolsky sign spread laterally with pressure, to the face, chest, breasts, abdomen, back, upper extremities, pelvis, perineum, buttocks, and bilateral thighs, involving 80% TBSA (fig. 1). Skin biopsy confirmed the diagnosis of TENS. Due to respiratory failure, the patient was intubated on the second day of admission and underwent a tracheostomy to maintain patency of her airway. Her laboratory values were within the normal range except for the following (normal values are indicated in parentheses): hemoglobin 11.7 (11.5-15.5) g/dl, Hct 33% (35.0-45.0), MCV 79.9 (81.1-96.6), white blood count 3.2 (4.5-13.0) x103/mm3 with 84% neutrophils, 12.8% lymphocytes, 1.9% monocytes, 0.1% eosinophils, 0.3% basophils, platelets 174 (185-395) x103/mm3, PT 14.5 (11.8-13.8) s, INR 1.19 (2.0-3.0), PTT 36.3 (25.6-34.4) s, fibrinogen 525 (196-457) mg/dl, D-dimer 4.89 (0.22-0.43), C-reactive protein 27.01 (0.0-0.50) mg/dl, prealbumin 8 (18-45) mg/dl, BUN 9 (10.0-20.0) mg/dl, creatinine 0.4 (0.6-1.4) mg/dl, calcium 7.3 (8.5-10.5) mg/dl, glucose 159 (65-110) mg/dl, phosphorus 2.4 (2.5-4.5) mg/dl, GGT 130 (3.0-60) mg/dl, LDH 246 (85-210) mg/dl, and Na 129 (135-145) mEq/l.
She became coagulopathic (PT 17.4 s, PTT 38.3 s). Sheet-like sloughing of her skin progressed, including the entire back. Her wounds were cleaned and covered with a silver dressing (ActicoatTM; Smith and Nephew, St. Petersburg, Fla., USA). Dressing changes occurred every 3-4 days. Bacitracin with zinc oxide was used to lubricate the face, scalp, and neck. She received a 5-day course of intravenous gamma globulin at 5 mg/kg/day. Corticosteroids were continued, and parenteral nutrition was initiated. After 2 weeks of electrolyte correction, fluid resuscitation, and topical wound care, she was stabilized, extubated, and her skin reaction resolved; the hospitalization lasted 23 days.