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We read with interest the article by Tincopa et al (1) regarding a 13-year-old African American girl presenting with bullous systemic lupus erythematosus. We have recently diagnosed another case of bullous systemic lupus erythematosus in a teenage girl that we would like to share.An 18-year-old African American girl presented to our dermatology clinic with a 3-week history of a vesicular eruption involving the oral mucosa, face, posterior auricular area, trunk, and buttocks. Per patient report, the vesicles began over her trunk and buttocks and progressed to include her face and mouth. The patient also reported a 3-month history of fatigue, arthralgia, and myalgia. On examination, she appeared tired. She had multiple 2-to 3-mm tense, fluid-filled vesicles over her bilateral cheeks, chin, posterior auricular area, and vermillion lip as well as erosions of her oral mucosa. Lesions on her trunk and buttocks had largely resolved, some replaced by crusting, others with residual postinflammatory hyperpigmentation. The patient had no significant past medical history and was taking no medications at the time of presentation. Family history was unremarkable for autoimmune diseases.Laboratory analyses at initial presentation were notable for an erythrocyte sedimentation rate of 79 mm ⁄ hour and C-reactive protein of 2.656 mg ⁄ dL. Complete blood count was notable for hemoglobin of 9.6 g ⁄ dL and hematocrit of 29.5%. Direct antiglobulin test was positive for hemolytic anemia. Urinalysis was unremarkable. Her antinuclear (ANA), double-stranded DNA, Smith, SCL-70, ribonucleoprotein, Jo-1, SS-A, and SS-B antibody panels were negative. Complement C3 and C4 were both low (51.8 mg ⁄ dL and 7.4 mg ⁄ dL, respectively). Viral cultures of vesicle fluid were negative for herpes simplex 1 and 2 and varicella zoster. Initial skin biopsies were obtained from the vermillion lip for hematoxylin and eosin (H&E) and direct immunofluorescence (DIF). Histology revealed a cell-poor subepidermal split; DIF revealed only granular deposition of C3 in the superficial and mid-dermal vessels.Because of high clinical suspicion, ANA was repeated 1 week later and found to be positive at a titer of 1:640. Biopsies for H&E and DIF were also repeated, this time from the left cheek. The H&E was notable for subepi-dermal clefting, scant neutrophils, and abundant mucin deposition. DIF demonstrated a broad ribbon-like pattern along the dermal-epidermal junction for immunoglobulin (Ig)G, IgA, IgM, and C3; salt-split skin was positive for IgG, IgA, and IgM on the floor of the blister. A diagnosis of bullous lupus erythematosus was made, and the patient was started on prednisone 40 mg daily (1mg ⁄ kg per day) and hydroxychloroquine 200 mg daily, which resulted in improvement of her fatigue, but she continued to develop new blisters. We are planning to admit her next week for intravenous immunoglobulin and pulse-dosed solumedrol.We feel this presentation of bullous lupus further supports Tincopa et al's conclusion to consider this diagnosis in the evaluation of ve...

Targeted molecular diagnostic tests and accurate immunoassays have transformed the landscape of clinical virology, calling into question the usefulness of traditional viral culture. Here we present a case where viral culture, followed by metagenomic sequencing, was central to the diagnosis of an unexpected viral infection, with significant clinical and public health implications.

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