A 76-year-old white woman presented with a history of emphysema, congestive heart failure, and rheumatoid arthritis. She had previously been treated with steroid inhalers for her lung disease and with nonsteroidal agents for her arthritis. She had no history of systemic immunosuppressive therapy, except for a single dose of methotrexate that she had taken the week before presentation.
She developed symptoms of bilateral eyelid redness and weeping the evening before admission and experienced general malaise with shaking chills and vomiting throughout the night. On waking the next morning, her eyelids were swollen and appeared bruised. She sought evaluation at her local hospital's emergency department. Her eyelids progressively worsened, developing more pronounced discoloration and a bullous appearance. She was transferred to our medical center for further evaluation.