SUMMARYLyell's syndrome or toxic epidermal necrolysis (TEN) is a rare dermatological disease that causes serious morbidity and mortality. It is most commonly drug induced. The authors report the case of a 57-year-old woman who was admitted to our hospital with severe rash all over the body. She had been previously submitted to brain surgery for total resection of a large meningioma and medicated with phenytoin for seizures prophylaxis. During this treatment, erythematous lesions and blisters were observed first on her face and trunk and then spreading to the entire body. Detachment of the skin, as well as mucous involvement especially of mouth and conjunctiva, was also observed. TEN was diagnosed, and phenytoin was discontinued. Intravenous fluids, systemic steroids and tightened infection control measures were implemented. After 10 days, skin recovery and reepithelialisation were established, temperature decreased and mucosal complications stabilised. The patient was discharged after 1 month of hospitalisation. BACKGROUND

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DESCRIPTIONA 55-year-old man with no clinically relevant medical history presented with a 7-day history of right-sided pleuritic chest pain, non-productive cough and night sweats. Physical examination showed no clinical signs of respiratory distress. The laboratory results revealed an elevated C-reactive protein of 5.02 mg/dl and an increased erythrocyte sedimentation rate of 110 mm/h. A posteroanterior chest radiograph showed a phantom tumour as a well-delineated, drop-shaped density in the right middle lung field (figure 1). A CT scan identified multiple mediastinal and right hilar lymphadenopathy, and confirmed a homogenous loculated effusion in the right major fissure, a so-called 'pulmonary pseudotumour'. A tuberculin skin test was strongly positive. A diagnostic thoracentesis showed a lymphocyte-rich exudative pleural effusion with a high level of adenosine deaminase.Tuberculous pleural effusion was diagnosed and a 6-month anti-tuberculosis standard regimen was started.Follow-up examination at the end of treatment revealed resolution of symptoms and radiograph showed complete resolution of the opacity.

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Background Methotrexate (MTX) is the most commonly used disease modifying anti-rheumatic drug (DMARD) for the treatment of rheumatoid arthritis (RA). Methotrexate pneumonitis (MP) is a potentially fatal hypersensitivity reaction with a mortality rate of ∼20%, the risk being maximal in the first year of treatment. The incidence of MP is higher in patients with pre-existing lung disease, particularly interstitial lung disease (ILD). Early identification of these patients provides the opportunity to offer an alternative agent. Prior to commencing MTX the current British Society for Rheumatology guidelines advise a screening chest radiograph (CXR). CXR has a low sensitivity for detecting ILD and it has been suggested that carbon monoxide transfer factor (TLCO) is a more sensitive marker. The guideline of the Rheumatology department at King’s College Hospital is to request a pulmonary function test (PFT) as well as a CXR prior to commencing MTX in all RA patients. If the TLCO is abnormal a high-resolution computerised tomography scan (HRCT) is considered. Objectives To investigate whether screening with PFT and CXR identifies more patients with ILD than screening with CXR alone. Methods 107 MTX-naive RA patients aged 21–86 who had previously had CXR and PFT were identified from the hospital database. Those patients with an abnormal TLCO (defined as ≤79% in non-smokers and ≤69% in smokers) who had undergone HRCT were included. Where ILD was identified on HRCT, the CXR was reviewed for abnormalities. Results Of the 107 patients, 44 with normal TLCO were excluded and a further 23 patients were excluded as they had not had HRCT. Of the 40 remaining patients, ILD was identified in 12 (see Table) of whom 6 (50%) had a normal CXR. 9 (75%) patients had early RA, defined as within 3 years of symptom onset. Of the 6 patients with abnormal CXR, 5 had TLCO <49% indicating advanced lung disease. Conclusions Our results show that the combination of CXR and PFT detects more patients with RA ILD compared to CXR alone, particularly in less advanced respiratory disease. In this cohort of RA patients undergoing pre-MTX screening we identified 12 patients with ILD, a prevalence of 11%. 50% of these patients would not have been identified by screening with CXR alone. MP is a rare but potentially fatal side-effect of MTX treatment. It is well recognized that prognosis is significantly worse in RA patients with ILD. Therefore we suggest early screening with PFT to identify these patients, allowing appropriately tailored management. References Disclosure of Interest: None Declared