toxic epidermal necrolysis ( ten ) is an extreme , rapidly - evolving skin disorder , which is characterized by extensive painful cutaneous exfoliation . also known as lyell 's syndrome , this dermatological condition can be life - threatening . the major cause of ten is medication hypersensitivity , thus the most effective treatment is the immediate withdrawal of the causative agent . due to the common development of large wounds with high risk of infection and resulting sepsis , patients suffering from ten should be treated in specialized centers . wound treatment regimens and the role of special wound dressings are still under current debate [ 3 , 4 ] . unexpected comorbidities and pathological findings may complicate the clinical picture , making management even more challenging for burn unit teams . in this context , we present a case of ten in a patient infected with human immunodeficiency virus ( hiv ) with the additional , unexpected diagnosis of dengue fever ( df ) . this case report highlights the importance of clinical vigilance on the part of intensive care staff to pursue additional diagnostic considerations when patient symptoms ( e.g. fever ) can not be explained by the routine causes . a 34-year - old african female came to the emergency room ( er ) of the rwth aachen university , aachen , germany , reporting fever up to 40c for a week and new painful blisters over her back and right arm with a rash over her whole body . she had a history of hiv infection for 10 years ( cd4+/cd8 + ratio : 0.1 ; cd4 + count : 208 ) treated during the last year with combivir ( 300 mg lamivudine and 150 mg zidovudine p.o . , 2 per day ) and kaletra ( 100 mg lopinavir and 25 mg ritonavir p.o . , 1 per day ) . after trying supportive care ( vitamins and micronutrients ) and pain relieving medications ( 500 mg acetylsalicylic acid p.o . , 2 per day ; 1 g acetaminophen p.o . , 4 per day ) for 5 days , the patient consulted a general practitioner . concerned about a bacterial infection , he empirically prescribed cefuroxime ( 250 mg p.o . , 2 per day ) and azithromycin ( 500 mg p.o . , 1 per day ) as well as fluconazole ( 50 mg p.o . , 1 per day ) . it became worse the following day , expanding over the whole body with painful blisters on her back and right arm . on examination by the internal er doctor , the patient ( weight : 85 kg , bmi : 29.4 ) was conscious and oriented . she was normotensive ( blood pressure 120/65 ) with sinus tachycardia ( heart rate 124/min ) . the blisters ranged between 0.5 and 4 cm ( fig . 1 ) and covered her trunk , abdomen , upper back , neck , and both arms ( right more pronounced than left ) , covering about 45% of the total body surface area . the er doctor , suspecting ten , called for the dermatologist and the burn surgeon for consultation . confirming the presumptive diagnosis , the patient was transferred to the intensive care unit ( icu ) for optimal treatment and further wound care . on admission to the icu , central venous access was secured and fluid resuscitation was initiated with lactated ringer 's solution . laboratory markers revealed an increase of crp ( 201 mg / l ) but not leucocytes . the serum protein ( 104 g / l ) and the ldh concentration ( 518 u / ml ) were elevated . the blisters were disinfected with octenisept ( 0.1 g octenidindihydrochlorid , 2.0 g phenoxyethanol per 100 ml ) , and covered with acticoat ( silver antibacterial protection ; smith&nephew , london , united kingdom ) and dry sterile gauzes . since all bacterial and fungal screenings remained negative , the focus of infection was unclear . upon consultation with the infectious disease service , empiric antibiotic and antifungal medications were started with avalox ( 400 mg moxifloxacin i.v . , 1 per day ) and ecalta ( 100 mg anidulafungin i.v . , 1 per day ) . three days after admission to the hospital , polymerase chain reaction testing for viruses revealed dna in serum of dengue virus . the patient had initially denied any recent travel , but after further questioning she admitted a recent visit to kenya . antimicrobials were stopped and fever began to decrease slowly on the fifth day of inpatient treatment . after 18 days of inpatient treatment , the patient was able to be discharged home . the cutaneous findings of ten result in acute macular erythematous rash with bulla , and red macules with central blistering . usually , the lesions rapidly exhibit the nikolsky 's sign ( epidermal separation induced by gentle lateral pressure of the skin surface ) which facilitates the diagnosis . besides affecting the mucosal and ocular surface , the lesions can become extremely extensive until a complete loss of epidermis within 24 h. thus , ten is associated with significant morbidity , including thermoregulatory disturbance and dehydration , and leads to lung , renal , liver and heart failure in severe cases . mortality is approximately 40% , but it depends on co - morbidity and individual factors . the risk of mortality can be assessed by a specific severity evaluation system , also known as the severity - of - illness score for toxic epidermal necrolysis or scorten . in our specific case the scorten score was calculated to be two . in the majority of the cases a drug reaction is the cause of ten . most commonly involved are several antibiotics ( sulfonamide , tetracycline , quinolones , -lactam ) , anticonvulsants ( phenytoin , carbamazepine ) , nonsteroidal anti - inflammatory drugs or alluporinol . to date , research has failed to demonstrate the mechanism by which exposure to a particular drug can lead to ten pathology . alternately , a combination of different drugs rather than a single drug may be the possible cause . in the presented case , however , we presume that the ten was a reaction to cefuroxime , azithromycin or the combination of both medications prescribed by the general practitioner . but this includes bone marrow transplant patients , individuals with systemic lupus erythematosus , only rarely persons with exposure to certain chemicals , and individuals receiving different vaccinations   as well as persons with hiv-1 infection . in our case , however , the possible involvement and contribution of an infection with the dengue virus and resulting df is unknown . transmitted by the aedes aegypti mosquito , df is a disease belonging to the family flaviviridae , genus flavivirus . df , as well as the more severe dengue hemorrhagic fever , is caused by four closely related viruses called dengue 1 through 4 ( denv 1 - 4 ) . dengue viruses are maintained in primitive rainforest cycles involving lower primates and mosquitoes in asia and west africa . however , den viruses can be transmitted in an urban cycle between humans and the highly domesticated mosquito . indeed , the a. aegypti proves to be a very efficient epidemic vector as den viruses are the only arboviruses that have fully adapted to humans and are maintained in large urban centers of the tropics . dengue virus infection in humans fortunately , the percentage of fatal cases is about only 5% , thus the majority of infections present an abrupt onset of mild febrile illness , which applies well to our presented case . however , because of the risk of a hemorrhagic fever , these patients have to be monitored carefully . df is a very old disease and has historically caused major public health problems due to wide epidemics during its starting period in the 17th until the early 20th century . the initial geographic expansion of df was closely tied to the global spread of a. aegypti mosquitoes from africa to other parts , but always remained in tropical regions . thus , infection in humans in temperate zones such as europe is usually acquired by exposure to mosquitoes in equivalent tropical regions . although the diagnosis of df in europe is rare , it should be taken under consideration amongst febrile returning travelers . intriguingly , in the past 30 years the den viruses have spread between countries and continents in the tropical regions , which increased its frequency in the pacific islands , south america and asia . but still , the infection of den virus is limited to tropical regions with occurrence of a. aegypti , and thus making its appearance in temperate zones very rare . however , this case report not only presents the illness of ten , but it demonstrates that staff in specialized centers has to be well aware of improbable findings as , for example , an uncommon virus infection . thus , it is important that treatment of ten always includes an interdisciplinary approach involving dermatologists , ophthalmologists , intensive care physicians , burn specialists , and beyond this , various other departments . to the best of our knowledge , we present for the first time a case of ten with df in a european icu . we emphasize that ten can be a complex and diverse illness resulting in total organ failure and shock in severe cases , and it is always challenging for an intensive care team , especially if rare pathological findings occur .
toxic epidermal necrolysis ( ten ) , also known as lyell 's syndrome , is a life - threatening disease with common development of large wounds . 
 thus , affected patients are usually treated in specialized centers . 
 herein , we present a case of ten in a patient infected with human immunodeficiency virus with the additional , unexpected diagnosis of dengue fever . in this context , we discuss cause , diagnosis , pathology , and treatment of ten and highlight the role of rare and unexpected findings , as in this case an additional tropical virus infection . 
 we underpin the importance of an interdisciplinary approach involving dermatologists , ophthalmologists , intensive care physicians , burn specialists and various other departments and emphasize the challenge of ten treatment , especially if rare pathological findings occur .