CASE 39: BLISTERS ON THE SKIN
History
An 83-year-old man presents to his general practitioner (GP) having developed multiple
blisters on his skin and mouth. The blisters have appeared over 2 days. They tend to burst
rapidly to leave a large red sore lesion. The patient has lost about 5 kg in weight over the
past 3 months and has a poor appetite. He feels generally unwell. He has also noticed that
his bowel habit has become erratic and has noticed some blood in his bowel motions. He
has previously been fit and had no significant past medical illnesses. He lives alone and
neither smokes nor drinks alcohol. He is taking no regular prescribed medication and has
not bought any medication from a pharmacy or health food outlet except some multivit-
amin tablets since he felt unwell.
Examination
He looks emaciated and unwell. There are blisters spread all over his skin and sores within
his mouth. Most of the blisters appear to have burst. His pulse rate is 102/min, irregularly
irregular and blood pressure 160/78 mmHg. Examination of his heart and respiratory sys-
tem is otherwise normal. There is a 6 cm hard nodular liver edge palpable, and also a hard
mobile mass present in the left iliac fossa. On rectal examination there is some bright red
blood mixed with faecal material on the glove.
NormalHaemoglobin 9.2 g/dL 13.3–17.7 g/dL
White cell count 6.2% 109 /L 3.9–10.6% 109 /L
Platelets 236 % 109 /L 150–440% 109 /L
Mean corpuscular volume (MCV) 72 fL 80–99 fL
Sodium 136 mmol/L 135–145 mmol/L
Potassium 3.8 mmol/L 3.5–5.0 mmol/L
Urea 5.2 mmol/L 2.5–6.7 mmol/L
Creatinine 94 &mol/L 70–120&mol/L
Albumin 32 g/L 35–50 g/L
Glucose 4.3 mmol/L 4.0–6.0 mmol/L
Bilirubin 16 mmol/L 3–17 mmol/L
Alanine transaminase 34 IU/L 5–35 IU/L
Alkaline phosphatase 692 IU/L 30–300 IU/LBlood film: hypochromic, microcytic red cellsINVESTIGATIONS
Questions
- What is the diagnosis of the skin disease?
- What is the cause of this condition in this patient?