Diagnose It Answer — April 30, 2026

27-year-old female admitted with a spreading painful skin rash that began on her face and chest 3 days ago and has rapidly progressed to cover her torso, arms, and back. She is in significant pain and states the skin 'burns.' She also has painful red eyes and blistering inside her mouth making it impossible to eat or drink. She started a new medication 2 weeks ago.

New onset epilepsy diagnosed 6 weeks ago — started on lamotrigine (Lamictal) 2 weeks ago, titrated rapidly. No prior history of drug reactions, allergies, or skin conditions. No OTC medications. No recent illness or infection before the rash. She reports the rash began as 'flat red blotches' on her face and has been spreading and blistering progressively over the past 3 days. She went to urgent care 2 days ago and was told it was 'a virus.'

BP 106/68 mmHg, HR 122 bpm, RR 20 breaths/min, Temp 39.1°C (102.4°F), SpO2 96% on room air. Patient is in significant pain and distress. Body surface area (BSA) assessment performed: confluent epidermal sloughing and blistering involving approximately 22% of BSA — straddling the SJS/TEN overlap definition (SJS: <10%, overlap: 10–30%, TEN: >30%).

Nikolsky's sign positive — gentle lateral pressure causes the epidermis to shear away from the dermis. Target/atypical target lesions with central necrosis present on the trunk. Mucosal involvement confirmed at 3 sites: oral mucosa, conjunctivae (bilateral), and genital mucosa. Lamotrigine discontinued immediately — causative agent removal is the single most critical intervention. Burn unit and dermatology consulted. Patient treated as a burn patient: IV morphine for pain, wound care with non-adherent dressings, ophthalmology for eye care, and nutritional support. Contact isolation initiated. Cyclosporine infusion ordered per dermatology protocol.

WBC 4,200/µL (leukopenia — poor prognostic sign on SCORTEN score). Albumin 2.2 g/dL (hypoalbuminemia — severe in the context of epidermal protein loss). BUN 28 mg/dL, creatinine 1.4 mg/dL (pre-renal AKI from insensible fluid loss through denuded skin). Na 130 mEq/L. Serum glucose 268 mg/dL. Serum bicarbonate 17 mEq/L (metabolic acidosis from fluid loss). CRP 188 mg/L. SCORTEN severity score calculated: 4 — predicted mortality 58.3%. Skin biopsy (punch): full-thickness epidermal necrosis with subepidermal blister formation and keratinocyte apoptosis — confirmatory for SJS/TEN spectrum. Blood cultures x2 drawn (secondary infection risk).