North Texas GME Research Forum 2024



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North Texas


Medical City Fort Worth


Internal Medicine

Document Type


Publication Date



bullous pemphigoid, blistering


Immune System Diseases | Internal Medicine | Medicine and Health Sciences | Skin and Connective Tissue Diseases


INTRODUCTION: When a patient presents with a blistering rash arriving at the diagnosis can seem overwhelming. Bullous Pemphigoid (BP) is the most common autoimmune blistering disease and tends to affect older individuals, with a mean age of presentation of eighty. It is caused by antibodies targeting the basement membrane zone, the structure between epidermis and dermis, specifically affecting the BP180 (Type-XVII collagen) and BP230 (a plakin) proteins. Antibody-antigen complexes lead to complement activation and destruction of these transmembrane proteins, causing separation of the epidermis and dermis, and formation of tense, subepidermal blisters and bullae. Identification of key clinical features and integrating them with ancillary testing will lead to a diagnosis. CASE PRESENTATION: An 81-year-old male presented with a pruritic, bullous eruption. He had tense blisters and bullae on his trunk, upper, and lower extremities. He also had areas of urticarial or hive-like plaques mixed with ulcerations with overlying serous crust. Unaffected skin did not easily blister with lateral pressure. Evaluation included HSV swab from the floor of a bullae and biopsies for histology and direct immunofluorescence (DIF). Due to the high clinical suspicion for bullous pemphigoid, he was started on systemic corticosteroids after the biopsies were collected. Histopathology and DIF were consistent with bullous pemphigoid. He improved on high-dose corticosteroids. We planned to taper steroids and start treatment with azathioprine. However, during his inpatient stay he was found to have metastatic adenocarcinoma of the gastrointestinal tract and was placed on hospice care. LEARNING POINTS: The differential diagnosis of a bullous eruption is broad and can be initially overwhelming. Blisters and bullae can be caused by many common diseases including herpes zoster, allergic contact dermatitis, insect bites, bullous impetigo, and edema bullae. However, they can also be caused by more uncommon disorders including disseminated herpes simplex, dermatitis herpetiformis, epidermolysis bullosa acquisita, pemphigus vulgaris, bullous pemphigoid, and Stevens-Johnson syndrome/toxic epidermal necrolysis. These conditions can be distinguished through detailed clinical history, physical examination, and ancillary testing. With these data, primary care physicians can better recognize, diagnose, and treat bullous disease, including bullous pemphigoid, in the inpatient and outpatient setting. Early recognition of these disorders may decrease morbidity and lower healthcare-associated costs.

Original Publisher

HCA Healthcare Graduate Medical Education

A Bullous Eruption in an 81-Year-Old Male



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