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Facial blistering eruption in a patient with acute respiratory failure

A 45-year-old female with a history of allergic rhinitis presented to the hospital with a 1-week history of productive cough, pleuritic chest pain and dyspnea, preceded by a 3-month history of intermittent hand numbness. She was found to be febrile, tachypneic and in type 1 respiratory failure that required intubation. An asymptomatic blistering eruption manifested shortly after admission. On physical examination, we found targetoid ulceronecrotic vesicles and bullae on a non-erythematous base on the patient's face (Figure 1). There was no mucosal involvement. Laboratory tests were significant for severe peripheral eosinophilia, and urinalysis revealed worsening renal function with microscopic hematuria. Autoimmune screening was positive for antinuclear antibody (titer 1 : 160, homogeneous pattern); double-stranded DNA and extractable nuclear antigen panel were negative. Test results for perinuclear antineutrophil cytoplasmic antibodies were positive and levels of anti-myeloperoxidase antibody were elevated (> 200 RU/ ml); test results for anti-proteinase-3 antibody were negative. Indirect immunofluorescence was negative. A computed tomography scan of the chest revealed bilateral airspace consolidation and ground glass opacity with reactive hilar and mediastinal lymph nodes (Figure 2). Bronchoalveolar lavage cytology showed inflammatory cells of mixed eosinophilic Facial blistering eruption in a patient with acute respiratory failure Case for Diagnosis