CASE
Following the delivery of a healthy
infant, the 28-year-old mother began to experience intense itching on her neck. Within 48 hours, the itching was even more intense and a rash had begun to appear on the trunk, arms, and legs.
Over the next week, the patient was seen in five different medical venues, including emergency rooms and urgent care clinics, and by an infectious disease specialist. During that time, she was given five different diagnoses: shingles, staphylococcal infection, contact dermatitis, herpes simplex, and pruritic urticarial papules and plaques of pregnancy (PUPPP). These diagnoses led to prescriptions for numerous medications, including oral and systemic corticosteroids, antiviral medications (acyclovir, valacyclovir), oral and systemic antibiotics (ciprofloxacin [Cipro] and ceftriaxone [Rocephin]), as well as oral and systemic antihistamines (diphenhydramine). Nevertheless, both the symptoms and the extent of involvement worsened, and she was referred to dermatology.
On examination, the patient was afebrile and did not appear ill. The rash was extensive, especially on the neck, arms, and legs, where large collections of vesicles and bullae were circumscribed by annular, erythematous borders (Figure 1). The bullae were uniformly tense and remained intact despite digital pressure, which also failed to extend the margins of the blisters. Results of laboratory studies ordered 4 days previously, including a CBC and comprehensive metabolic panel, were within normal limits.
Using a 4-mm punch, specimens of perilesional skin were obtained for routine hematoxylin and eosin processing and direct immunofluorescent studies. The pathology report showed IgG deposited along the basement membrane as well as subepidermal vesicles, all consistent with a diagnosis of pemphigoid gestationis (PG), a rare blistering disease associated with pregnancy.
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