The diagnosis is in the rings

A 62 year old man reported a history of recurrent oral ulcers, sometimes with laryngitis, and conjunctivitis. He consulted his doctor in 2011 for acute onset fever (39°C), odynophagia, and laryngitis lasting two days, and was prescribed ibuprofen and clarithromycin. Two days later, conjunctivitis, oral mucous membrane erosions, and cutaneous lesions appeared. The patient was hospitalised on suspicion of Stevens-Johnson syndrome.

Dermatological examination showed several target lesions on the trunk, lower limbs, and scrotum (fig 1, 2⇓), conjunctivitis (fig 3⇓), and diffuse erosions of the mucous membranes involving the mouth (palate, tongue, buccal mucosa, and lips) (fig 4⇓), and glans. Examination of ear, nose, and throat showed diffuse nasal erosion, crusts, and epiglottal erosion. The patient had no dysuria, pain with defecation, or pulmonary symptoms. His general condition was poor, with fever, fatigue, and difficulty eating.

Blood examination showed normal blood cell counts, increased C reactive protein (160 mg/L), negative herpes simplex virus culture from the mouth and skin, and negative HIV, herpes simplex virus, Mycoplasma pneumoniae, and Chlamydia pneumoniae serologies. Skin biopsy showed a dense lichenoid lymphocytic infiltrate with necrotic keratinocytes in the basal layer. Direct and indirect immunofluorescence tests were both negative.