sigmoid diverticulosis has a prevalence of up to 60% in 70-year - old individuals , of whom 1025% may progress to diverticulitis and a further 1025% of these may develop complications such as abscess formation , perforation or fistulas . the mortality rate has been demonstrated to be 0.55% .
the most common symptoms include left lower abdominal pain lasting for a few days , fever , nausea and vomiting , and abdominal tenderness and rigidity during clinical examination .
false diverticulum , e.g. only the mucosa and submucosa herniate through the muscular layer of the gut .
risk factors include , among others , obesity and chronic constipation . the pathophysiological process of sigmoid diverticulitis is primarily thought to be erosions caused by pressure exerted in the sigma , in combination with feces and microbial toxins which form microabscesses .
these erosions develop into ulcers which may then perforate , either covered by peritoneum , or freely , into the abdominal cavity .
toxic epidermal necrolysis ( ten ) is caused by a severe inflammatory reaction , most probably of autoimmune origin .
it is characterized by cytotoxic t - lymphocytes and other cytokine pathways , causing keratinocyte apoptosis and thereby disruption of the epidermis from the dermis of the skin .
it presents clinically with fever , itchy eyes , pain upon swallowing and cutaneous efflorescences such as erythematous purpuric macules on the trunk and proximal upper extremities as well as on the lips and oral , conjunctival and genital mucosae .
the epidermal skin lesions progress to full - walled necrosis , materializing as epidermal detachment and resulting in blisters . a positive nikolsky sign can be elicited , and the skin resembles wet cigarette paper when detached . stevens - johnson syndrome affects less than 10% of the total body surface area ( tbsa ) and has an incidence of approximately 6 cases per million persons per year , with an average mortality rate of 15% .
ten involves more than 30% of the tbsa and affects approximately 2 persons per year with an average mortality rate of 2550% [ 2 , 3 ] .
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 .
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 .
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 .
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/l . moreover , she presented with lymphocytopenia ( lymphocyte count 500/l ) , renal insufficiency ( creatinine 121 mol / l ) and a hypokalemia level of 2.7 mmol / l .
free air in the abdominal cavity and signs suggestive of perforated sigmoid diverticulitis were observed ( fig .
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 3040% of her tbsa . a direct nikolsky sign could be elicited , and an attempt at an indirect sign was negative . following surgery ,
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 matter under discussion is whether the perforated sigmoid diverticulitis in our patient developed due to the epidermolysis resulting from an adverse reaction to medication , or whether it evolved independently .
a review of the literature shows very few cases of simultaneous ten with ulcerative gastrointestinal disease , and only 1 case of ten with perforated sigmoid diverticulitis . a study from 1991 by chosidow et al .  
three out of the 4 patients showed severe mucosal erosive lesions in the small intestine ; similar changes were also found in the colon of all patients .
epithelial cell necrosis could be observed predominantly in the sigmoid and rectum , resulting in detachment of the epithelial lining .
similarly , very few other cases have been published describing superficial erosions with bleeding throughout the colon in the context of ten [ 5 , 6 , 7 , 8 , 9 , 10 , 11 ] .
these cases , however , were not complicated by perforation of the colon , as ours was . to date , only 1 case of sigmoid perforation in the presence of ten has been reported , by carter and mitchell . the patient presented with cutaneous changes characteristic of ten , in addition to renal insufficiency . in the course of 1 week , the patient complained of worsening abdominal pain associated with coffee - ground emesis and blood per rectum .
an abdominal ct scan revealed a pneumoperitoneum , upon which surgical exploration was carried out .
fecal peritonitis , complete necrosis of the terminal ileum as well as multiple colonic perforations along the sigmoid and cecum were identified . an ileal resection and total colectomy
histological workup of the resected specimen demonstrated complete necrosis of the ileum and focal necrosis of the colon , with several areas of linear mucosal ulcerations showing lymphohistiocytic inflammatory infiltrate . after a long course of antibiotics and supportive
there are very few reported cases of perforated ulcerative conditions in the gastrointestinal tract due to mucosal necrolysis .
some authors suggest a similar immunologic pathogenesis as for toxic epidermal necrolysis [ 11 , 12 ] .
endoscopic biopsies have shown an increase in lymphoid cells , with no abnormal number of neutrophils or existence of crypt abscesses .
histological workup demonstrated pathological changes characteristic of diverticulitis , but no lymphocytic infiltrate characteristic of ten .
however , our patient had lymphocytopenia , possibly indicating migration of lymphocytes to dermal tissues .
also , her medication had been changed from paracetamol to metamizole approximately 3 weeks prior to developing ten , corresponding to the time average reported so far . in all cases reported to date , patients presented with abdominal pain , bloody diarrhea or blood per rectum , usually simultaneous to the development of skin lesions .
diagnosis was supported by colonoscopy showing mucosal erosions , predominantly in the sigmoid and rectum .
our patient did not present with the abovementioned symptoms , and colonoscopy could not be performed due to the upcoming surgery . only carter and mitchel  
have reported free sigmoid perforation in the presence of ten from which the patient recovered successfully .
patients discussed in other cases , as well as ours , died , proving the severity of the condition . the condition 's outcome can be estimated using the scorten score .
our patient acquired a score of 4 points ( age > 40 years , tbsa affected > 10% , serum urea nitrogen > 28 mg / dl , bicarbonate
< 20 mmol / l ) , which is associated with a mortality of 60% .
this may be indicative that an early and aggressive surgical approach is crucial in order to successfully avoid abdominal sepsis and increase survival rates .
she presented with an affected tbsa and temporal development similar to previously reported cases of ten with intestinal involvement .
, ten has a low incidence rate , but continues to result in serious , potentially fatal outcomes .
although the condition predominantly affects the skin , other areas such as the oral , esophageal as well as colonic ( especially the sigmoid ) mucosae may be affected .
it has been shown that gastrointestinal involvement may increase mortality dramatically by rapidly progressing to transmural ulcerations causing fecal peritonitis .
medical staff must therefore be alert to all patients with ten who complain of abdominal discomfort .
 even though the incidence of toxic epidermal necrolysis ( ten ) is low , it is also associated with a high mortality rate . 
 the condition predominantly affects the skin , but may also affect the gastrointestinal tract , dramatically increasing mortality . 
 we present a case of perforated sigmoid diverticulitis in the presence of ten . 
 the patient was taking medication , known to be a risk factor , and presented an affected total body surface area and temporal development similar to previously reported cases of ten . 
 characteristic abdominal symptoms , however , 
 were missing . gastrointestinal involvement in ten appears to be a poor prognostic factor ; medical staff must therefore be alert to patients with ten who complain of abdominal discomfort . 
 the exact pathogenesis , however , remains unclear . 
Introduction
Case Report
Discussion
Disclosure Statement