Sudden onset of melanuria in a patient with metastatic melanoma and toxic epidermal necrolysis

A 46‐year‐old man presented to our institution with blisters and eruption on the body and oral mucosa. He had a history of metastatic melanoma to the brain and had undergone radiation therapy to the head and chemotherapy with temozolomide. He was then started on dexamethasone and phenytoin. One month later, he developed a fever of 39.5 °C and an eruption in the axilla and groin. He was admitted to another hospital with a presumptive diagnosis of disseminated herpes zoster and was started on acyclovir, vancomycin, methylprednisolone, and fluconazole. The phenytoin was discontinued. Three days after admission, the eruption progressed and the patient developed respiratory distress. Biopsies from several lesions showed focal necrosis of keratinocytes with minimal superficial perivascular inflammation, consistent with toxic epidermal necrolysis. He was intubated and transferred to our medical center. On physical examination, the patient had exfoliation of over 70% of his body surface area ( Fig. 1 ), and scattered blisters were observed on the hands, chest, abdomen, and back. He also had crusted hemorrhagic plaques on the lips and conjunctiva. The patient was admitted with a diagnosis of toxic epidermal necrolysis, secondary to phenytoin.

Figure Figure 1  Open in figure viewer PowerPoint Extensive desquamation over the patient’s flank and thigh