Generalized edema with erythroderma

A 20-year-old girl presented with a one-week history of fever and chills, malaise, generalized erythema (including the face, trunk, back and extremities), edema (initially the face and then lower limbs) and hoarseness (Figure 1). Physical examination revealed low-grade fever, jaundice, lymphadenopathy (posterior cervical, submandibular, <1 cm, no axillary, no inguinal). Dermatological examination showed diffuse erythema (erythroderma), edema (generalized, especially periorbital and lips), and mild jaundice (scleral and sublingual). No mucosal lesions or nail changes were seen. She had a history of epilepsy since 3 years ago and had been under treatment with sodium valproate until 1.5 month ago when she discontinued the medication. She had an epileptic attack then and therefore carbamazepine was started for her. Positive laboratory findings were anemia, leukocytosis with eosinophilia (20%), elevated liver enzymes, and direct hyperbilirubinemia. Other routine laboratory tests, electrocardiogram, chest x-ray, and viral markers (including HBV, HCV and EBV) were unremarkable. Abdominal sonography revealed thickening of gall bladder and fluid in posterior choledosac. A punch biopsy was taken from her forearm skin.