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To the Editor.—
Dr. Voron's comments are greatly appreciated and point out another important cause of bullae in the comatose patient, namely pressure necrosis of skin. However, there were two reasons for excluding this possibility in our patient and for considering the bullous lesions to be "spontaneous." First, the absence of sweat gland necrosis in the premortem skin biopsy specimen is important, as Dr. Voron notes. Second, and not clearly stated in our description of the patient, the lesions over the chest were not in apposition to those on the arm. Because of their location, in fact, we did not believe that the pathogenesis of all the bullae seen could be related to this cause. Therefore, we stand by our interpretation that there is a suggestive association between the infection and the appearance of bullae in this patient. Further clinical observations may or may not support this hypothesis; however, this
Keusch GT. Bullae Due to Pressure-Reply. Arch Dermatol. 1975;111(4):528. doi:10.1001/archderm.1975.01630160118026