PMC5777104_01
Representative image of the skin lesions observed, en cocarde covered by scales that were only adherent in the center of the lesions and exhibited a pale center on the posterior trunk.
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St. Spiridon Emergency Hospital, Iasi, Romania), with a skin rash consisting of erythematous-papular erythema multiforme-like lesions on the skin, primarily located on the trunk and limbs in (Fig. 1). Clinical dermatological examination (Fig. 1) revealed erythematous-edematous macules and plaques, which were well-defined, round and arranged en cocarde, with a tendency to expand and evolve into placards.
Miscrocopy observation of lesion biopsies. (A) Hematoxylin and eosin staining. Magnification, x100. (B) Positive complement component 3 staining via direct immunofluorescence. Magnification, x100.
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Histopathologically, the following features were identified: Areas of atrophied epidermis with exocytosis, vacuolization and foci of necrotic keratinocytes, and a moderate inflammatory perivascular and peridnexal mononuclear infiltrate (Fig. 2A). Direct immunofluorescence revealed complement component 3 (C3; Fig. 2B) and immunoglobulin M in the basement membrane (data not shown).
Favorable outcome following treatment and subsequent relapse. (A) Skin lesions on the posterior trunk improved. (B) Relapse of the lesions en cocarde on the face.
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Therapy with systemic corticosteroids (methylprednisolone; 0.5 mg/kg) in combination with immunomodulators (azathioprine; 50 mg/day) was initiated in October 2015, which together with the associated medication (omeprazole, 20 mg/day; KCl, 1 g/day) and topical dermocorticoids (fluticasone propionate 0.05% cream; 1 application/day) markedly reduced the patient's symptoms (Fig. 3A). When a dose of 8 mg/day methylprednisolone was reached in May 2016, the patient noticed the reoccurrence of erythema multiforme-like lesions on their trunk, upper limbs and face (Fig. 3B).