SHM Converge Scientific Abstract ePoster Gallery-Peeling Back the Diagnosis: A Case of Erythroderma Secondary to Severe Eczematous Dermatitis

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This case describes a 62-year-old man with CKD, COPD, and HFpEF who was hospitalized for painful, full-body erythroderma involving 95% of his body surface area. He had a prior history of a leg rash that temporarily improved with topical clobetasol and tacrolimus, but he was lost to follow-up. At presentation, he also reported 40 pounds of unintentional weight loss. Examination showed widespread confluent erythematous plaques with thick scale over the head, face, trunk, and all extremities.<br /><br />Because erythroderma can be caused by psoriasis, atopic dermatitis, drug reactions, infection, or malignancy, the team pursued urgent evaluation, especially to rule out cutaneous T-cell lymphoma (CTCL) and other cancer-related causes. Initial labs showed anemia, thrombocytosis, elevated LDH, and no eosinophilia. Blood cultures grew MRSA, likely from skin barrier breakdown, and he was treated with vancomycin. He also required aggressive IV fluid replacement for dehydration related to extensive skin involvement.<br /><br />Dermatology performed two punch biopsies before prolonged steroid exposure. The patient was started on IV methylprednisolone, then transitioned to oral prednisone, topical steroids, and wet wraps. However, after a week he developed dyspnea, hypoxemia, and edema consistent with HFpEF exacerbation, so IV fluids were stopped and diuresis was initiated.<br /><br />Pathology showed psoriasis-like changes with subacute to chronic spongiotic/eczematous dermatitis. Flow cytometry and immunohistochemistry revealed an elevated CD4:CD8 ratio but no evidence of CTCL or B-cell malignancy, and T-cell clonality testing was negative. The final presumed diagnosis was severe atopic dermatitis causing erythroderma.<br /><br />The key lesson is that erythroderma is a medical emergency requiring early dermatology involvement, biopsy before steroids when possible, malignancy exclusion, and careful fluid management because resuscitation can worsen cardiopulmonary disease.

Asset Subtitle

David Haughey

Meta Tag

Author List David Haughey, Samy Amkieh

Category Clinical Vignettes

Concept Erythroderma

Concept Dermatologic Emergency

Concept Skin Biopsy

Concept Fluid Resuscitation

Concept Differential Diagnosis

Distinguished Non-Finalist

Presenter Organization Dartmouth Hitchcock Medical Center

Presenting Author David Haughey

Track Adult

Keywords

erythroderma

atopic dermatitis

psoriasis

cutaneous T-cell lymphoma

skin biopsy

spongiotic dermatitis

MRSA bacteremia

heart failure exacerbation

fluid management

dermatology

Erythroderma

Dermatologic Emergency

Skin Biopsy

Fluid Resuscitation

Differential Diagnosis