A 6-year-old girl with extensive bullous skin lesions.

A 6-year-old previously healthy girl presented with extensive bullous skin lesions involving approximately 25% of her total body surface area (TBSA). She initially presented 9 days earlier with low-grade fever, bilateral non-exudative conjunctival injection, cough, and rash. Her rash appeared as raised, erythematous target lesions that began behind her ears and then progressed to involve her face and body. Her symptoms at first presentation were attributed to erythema multiforme and she was treated with hydroxyzine and olopatadine eye drops. Five days later, fluid-filled bullae developed at the centers of the target lesions and increased in number and size up to the time of admission. Physical examination on admission revealed a nontoxic-appearing girl with extensive fluid-filled bullous lesions of varying sizes behind her ears, around her eyes and mouth, and on her neck, trunk, back, axillae, and perineum (Figures 1 and 2). Mucous membrane involvement included small bullae in her nares, hard palate, and perianal region. She had scattered bullae on her wrists and ankles, although her extremities were relatively spared. The skin at the base of the bullae was erythematous, slightly raised, and pruritic. Initial work-up included a normal complete blood count and electrolytes, clear chest radiograph, and negative herpes simplex virus antigen swab from one of her lesions. She was admitted to the hospital for wound care, pain control, nutritional support, and diagnostic evaluation. She continued to develop bullae during her initial hospital days until approximately 60% of her TBSA was affected (Figure 3, see page 230). Her palms and soles also developed lesions. Further testing and a skin biopsy revealed the diagnosis. Rheumatology