A 78 year old female with pulmonary hypertension and diastolic congestive heart failure presented to the emergency room secondary to shortness of breath and a rash. The shortness of breath began three days prior to admission and was associated with lower extremity swelling. Her rash began at the same time and was described as pruritic blisters on all four extremities. On physical exam, she was found to have bilateral lung crackles, a cardiovascular exam that demonstrated a regular rate and rhythm without any murmurs, 2+ bilateral lower extremity pitting edema with diffuse skin excoriations and bullae on all extremities. She was subsequently admitted for an acute congestive heart failure exacerbation and for further workup of her rash. A punch biopsy demonstrated bullous pemphigoid and it was presumed to be incited by the initiation of a new pulmonary hypertension medication. After cessation of medication, intravenous steroids and antihistamines were initiated. While the bullae were resolving, the patient continued to scratch her extremities despite aggressive skin care and unna boot placement. On day 5 of hospitalization, the patient developed a fever and subsequent blood cultures demonstrated MRSA Bacteremia. Vancomycin was initiated and the patient clinically improved until she developed acute respiratory distress two days later. On physical examination, a new 3/6 systolic murmur was identified and subsequent transesophageal echocardiogram demonstrated multiple vegetations on the mitral valve with severe mitral valve regurgitation. The patient was transferred to the intensive care unit secondary to acute respiratory failure and subsequently passed away several days after.
Bullous pemphigoid is an uncommon autoimmune blistering disease that affects the skin. It is seen in the elderly and is associated with a 6 fold increase in mortality as compared to age and sex matched subjects in the general population. A skin biopsy is the gold standard of diagnosis and the first line therapy includes either topical or systemic steroids and appropriate daily skin care. Currently, there is no definitive best approach to skin care in such patients aside from rupturing blisters under sterile conditions. In this case, all attempts at minimizing the patient’s symptoms were attempted including steroids, antihistamines and even placing unna boots on her extremities to promote healing and prevent scratching. However, despite all medical efforts, she continued to scratch her bullae and subsequently developed MRSA bacteremia leading to endocarditis and ultimately her demise.
To cite this abstract:Chernyavsky S, Mecca J, Narag K. Bullous Pemphigoid and Endocarditis: A Case of Mrsa Gone Awry. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 482. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/bullous-pemphigoid-and-endocarditis-a-case-of-mrsa-gone-awry/. Accessed April 9, 2020.