Patient: Male, 76 Final Diagnosis: Drug induced bullous pemphigoid Symptoms: Skin rash Medication: Cephalexin Clinical Procedure: Skin biopsy Specialty: General and Internal Medicine Objective: Unusual clinical course Background: The hallmark of bullous pemphigoid (BP) is widespread tense blisters arising on normal or erythematous skin, often with marked pruritus, the diagnosis of which is confirmed by direct immunofluorescence (DIF). BP is an autoimmune process that can be induced, though rarely, by medications. Drug-induced BP often has atypical clinical presentation, which requires a good understanding of other dermatological conditions with similar presentations, in particular, bullous subtype of erythema multiforme. End organ involvement warrants differentiating it from one of the severe cutaneous adverse reaction (SCAR) syndromes. Case Report: A 76-year-old African American male presented with extensive targetoid purplish skin lesions that clinically resembled atypical erythema multiforme, and one tense blister that raised a concern for BP. The patient presented 6 weeks after treatment with cephalexin for a urinary tract infection. Initial workup showed serum eosinophilia, acute kidney injury and eosinophiluria requiring deliberations on SCAR syndromes. A skin biopsy at an intralesional location showed a negative DIF, however, a skin biopsy at a perilesional site showed a positive DIF, confirming the diagnosis of BP. Conclusions: This case demonstrates an atypical presentation of BP induced by drugs. It emphasizes the need for a greater level of awareness of diagnosis and treatment of the various entities that fall under adverse drug reactions in the elderly. It also highlights the need for appropriate choice of skin biopsy techniques (intralesional versus perilesional) to avoid misdiagnosis, as well as lessons on how to approach dermatologic conditions with end organ involvement for hospitalists and other medical professionals who routinely deal with undifferentiated disease conditions.

A 21-year-old woman was found to have fulminant myocarditis as a result of Coxsackie B infection (a virus shown to exhibit summer-fall seasonality) in mid-December. In this case report, seasonality of enteroviruses is examined, as well as additional factors which may contribute to sporadic cases during winter months. The case report also discusses clinical criteria for endomyocardial biopsy, utility of PCR vs. antibody serological tests, coinfection with multiple serotypes, and rhabdomyolysis in Coxsackie B.

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Sepsis and septic shock are life-threatening conditions that remain an enormous burden of morbidity and mortality to millions of patients globally and cause organ dysfunction, leading to death in as many as one in four patients, often even more. Early management and appropriate treatment are essential to improve outcomes and reduce morbidity and mortality. In 2016, the Third International Consensus Definition for Sepsis and Septic Shock (Sepsis-3) defined sepsis as life-threatening organ dysfunction resulting from dysregulated host responses to infection, and defined septic shock as a subset of sepsis in which underlying circulatory, cellular, and metabolic abnormalities are profound enough to substantially increase the risk of mortality. That same year the group also implemented the application of the sequential organ failure assessment (SOFA) score over the systemic inflammatory response syndrome (SIRS) score. Sepsis in pregnancy remains a leading cause of maternal morbidity and mortality worldwide, with no current standard definition for severe sepsis for the pregnant or peripartum woman. The prevalence of pediatric septic shock is on the rise and brings with it the consequences of long-term morbidity and also death. Since the advent of programs for early recognition and treatment, mortality has decreased. Even so, globally, many children succumb to septic shock despite evidence-based care and years of research.