SHM Converge Scientific Abstract ePoster Gallery-Diagnostic Dilemma: Recurrent Mucocutaneous Reactions to Antifungals With Overlapping Stevens-Johnson Syndrome and Lichen Planus in a Patient With Chronic Lymphocytic Leukemia

Diagnostic Dilemma: Recurrent Mucocutaneous Reactions to Antifungals With Overlapping Stevens-Johnson Syndrome and Lichen Planus in a Patient With Chronic Lymphocytic Leukemia

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This case describes a 59-year-old man with chronic lymphocytic leukemia who developed recurrent painful oral ulcers, lip swelling, and a spreading rash while being treated for suspected candidiasis with antifungal medications. His symptoms initially improved with steroids, raising concern for a drug hypersensitivity reaction, possibly Stevens-Johnson syndrome (SJS). However, the clinical picture was complicated by a skin biopsy that confirmed lichen planus.<br /><br />The patient first presented with oral plaques and ulcerations and was treated for oral or oral-esophageal candidiasis with fluconazole and later micafungin. After discharge on fluconazole, he returned with severe mucosal blistering, facial/lip swelling, and a pruritic rash. Fluconazole allergy with evolving SJS was suspected, so the drug was stopped and steroids plus antihistamines were given. Although he improved, symptoms recurred after micafungin exposure, prompting another hospitalization. A punch biopsy of the back ultimately showed lichen planus.<br /><br />The authors highlight the difficulty of distinguishing drug reactions from autoimmune or inflammatory skin disease in immunocompromised patients. The improvement with steroids could fit either drug hypersensitivity or severe lichen planus, but pathology provided the strongest diagnostic evidence. They conclude that this may have represented lichen planus flare, a drug-induced lichenoid eruption, or a misdiagnosed SJS-like presentation.<br /><br />The key lesson is that broad differential diagnosis, early dermatology involvement, and prompt biopsy are essential when evaluating severe mucocutaneous eruptions in patients with cancer or immune dysfunction.

Asset Subtitle

Jonathan D. Grube

Meta Tag

Author List Angelica McCaskey, Anum Umer, Heena Patel, Jonathan D. Grube, Mandeepsinh Vashi, Mitra Chandan, Patrick Vickers

Category Clinical Vignettes

Concept Drug Hypersensitivity

Concept Lichen Planus

Concept Mucocutaneous Disease

Concept Stevens-Johnson Syndrome

Concept Biopsy

Distinguished Non-Finalist

Presenter Organization UCF/HCA Ocala Internal Medicine Residency

Presenting Author Jonathan D. Grube

Track Adult

Keywords

chronic lymphocytic leukemia

oral ulcers

Stevens-Johnson syndrome

drug hypersensitivity

lichen planus

fluconazole

micafungin

mucosal blistering

skin biopsy

immunocompromised patient

Drug Hypersensitivity

Lichen Planus

Mucocutaneous Disease

Stevens-Johnson Syndrome

Biopsy