PMC10208780_01
Photographs of physical findings. a: Persistent generalized pruritic erythema and pinhead-sized papules were noted on the back of the trunk (A) and thigh (B). b: The lesions on the back of trunk (A) and thigh (B) progressed to erythroderma with significant hyperkeratosis. Severe skin lesions were seen on the lower side of the eye, inner thighs (C), and back of the hands (D).
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Persistent generalized pruritic erythema and pinhead-sized papules were noted on the trunk and legs (Fig. 1a). Severe skin lesions were noted also on the lower side of the eyes, inner thighs, and back of the hands (Fig. 1b).
Skin biopsy findings. a: The first skin biopsy. A: Neutrophil infiltration was seen in the upper dermis (original magnification x20). B: Dyskeratotic cells (arrows) were seen in the epidermis and epidermal intercellular edema (original magnification x30). A, B: Hematoxylin and Eosin (H&E) staining. C: CD3 (+) lymphocytes (original magnification x20). D: CD8 (+) lymphocytes (original magnification x20). E: CD15 (+) lymphocytes (original magnification x20). b: The second skin biopsy. A: Neutrophil infiltration (black arrow) in the parakeratotic layer was newly observed, and dyskeratotic cells (white arrows) were more prominent in the epidermis (original magnification x30). B: Neutrophil, lymphocyte, and eosinophil infiltration was more prominent in the epidermis (original magnification x30). C: Neutrophil, lymphocyte, and eosinophil infiltration was more prominent in the upper dermis, as was edema of the epidermal-dermal junction (original magnification x30). A-C: H&E staining. D: CD3 (+) lymphocytes (original magnification x20). E: CD8 (+) lymphocytes (original magnification x20). F: CD15 (+) lymphocytes (original magnification x20). G: CD4 (+) lymphocytes (original magnification x20). c: The bone marrow biopsy. Hemophagocytic cells (arrows) were observed.
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Perivascular edema with CD3- and CD8-positive lymphocytes and CD15-positive neutrophil infiltration were seen in the upper dermis (Fig. 2a). The infiltration cells in the upper dermis were positive for CD3, CD8, and CD4 lymphocytes and CD15 neutrophils (Fig. 2b).
PMC10208780_02
Clinical course. TCZ: tocilizumab, Tac: tacrolimus, MTX: methotrexate, PSL: prednisolone, BT: body temperature, CRP: C-reactive protein, LDH: lactate dehydrogenase
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PSL was discontinued after 3 years (Fig. 3).