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- Presentation
Inpatient Dermatology Pearls and Pitfalls: SJS Mimics and Disseminated BCG Infection
Description
The talk presented two inpatient dermatology cases highlighting diagnostic pitfalls. In the first, a critically ill woman with breast cancer on pembrolizumab and recent broad-spectrum antibiotics developed a painful blistering eruption that initially looked like Stevens-Johnson syndrome/toxic epidermal necrolysis because of Nikolsky positivity and epidermal erosions. However, biopsy with direct immunofluorescence showed linear IgA along the basement membrane, revealing drug-induced linear IgA bullous dermatosis, likely vancomycin-related, and emphasizing the need to include DIF in the workup of suspected SJS and to remember that immune checkpoint inhibitors can cause atypical, less mucosal-predominant SJS-like eruptions. The second case involved an older man with a scrotal ulcer after intravesical BCG for bladder cancer, plus aortic and paraspinal abnormalities. Biopsy and culture demonstrated acid-fast bacilli, leading to a diagnosis of disseminated Mycobacterium bovis infection from BCG therapy with probable cutaneous, vascular, and deep tissue involvement; he improved on rifampin, isoniazid, and B6. The speaker closed with practical inpatient dermatology advice: join the inpatient team longitudinally when possible, use the hospital setting for more aggressive treatment and monitoring, and take advantage of hospital resources such as nursing support, case management, and social work.
View moreConclusions
- In hospitalized patients with blistering eruptions, drug-induced linear IgA bullous dermatosis can closely mimic Stevens-Johnson syndrome and direct immunofluorescence may be essential to distinguish them.
- Immune checkpoint inhibitors can produce both classic rapid-onset SJS and a slower atypical mucocutaneous eruption that may require a second trigger.
- Vancomycin should remain a leading suspect in drug-induced linear IgA bullous dermatosis when the presentation resembles SJS/TEN.
- Intravesical BCG therapy for bladder cancer can cause disseminated Mycobacterium bovis infection, sometimes presenting first with cutaneous lesions such as ulceration.
- Because BCG-related infection has variable and often nonspecific manifestations, clinicians should maintain a low threshold for skin biopsy and mycobacterial culture.
- Disseminated disease is the most common presentation of BCG-associated Mycobacterium bovis infection, while cutaneous and isolated vascular presentations are uncommon but important.
- Inpatients with complex dermatologic disease may benefit from longitudinal dermatology involvement rather than a one-time consult.
- The hospital setting allows more aggressive treatment and closer monitoring, which can be advantageous for severe inflammatory and autoimmune skin disease.
- Molina, Gabriel E., et al. "Generalized bullous mucocutaneous eruption mimicking Stevens-Johnson syndrome in the setting of immune checkpoint inhibition: a multicenter case series." Journal of the American Academy of Dermatology 83.5 (2020): 1475-1477.#10.1016/j.jaad.2020.03.029
- Asín, María Asunción Pérez-Jacoiste, et al. "Disseminated Mycobacterium bovis infection following intravesical BCG therapy." Medicine, 2014; 93.17: 236-254.
- Varanasi, P., et al. "Disseminated Mycobacterium bovis Infection Following Intravesical BCG Therapy." American Journal of Transplantation, 2025.