Abstract

Sudden Conjunctivitis, Lymphopenia, and Rash Combined with Hemodynamic Changes (SCoRCH) is a recently documented hypersensitivity reaction to trimethoprim-sulfamethoxazole (TMP-SMX). In the literature, one case of histologic findings in SCoRCH exists, described as a superficial perivascular dermatitis. We present a case of SCoRCH in a 53-year-old woman who underwent treatment with TMP-SMX for 10 days before developing a diffuse, burning red eruption. Symptoms emerged 4 days after completion of TMP-SMX and prompted hospitalization. Physical exam demonstrated facial edema, bilateral conjunctivitis, and tender, edematous, and erythematous macules coalescing into patches on the patient’s face, neck, trunk, and proximal extremities. Blistering, desquamation, lymphadenopathy, and mucosal involvement were absent. The patient was hypotensive. Laboratory assessment revealed transaminitis and lymphopenia. Other laboratory tests were within normal limits, including creatinine and eosinophil count. The differential diagnosis included Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (SJS/TEN), Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), morbilliform drug eruption, erythema multiforme (EM), and SCoRCH. Punch biopsy captured a vacuolar interface dermatitis with apoptotic keratinocytes throughout the epidermis. Within two days of admission, the patient’s cutaneous eruption, hemodynamic instability, and laboratory abnormalities resolved spontaneously, favoring SCoRCH. This is the first report of SCoRCH presenting with a vacuolar interface dermatitis and apoptotic keratinocytes. Histopathologically, SCoRCH may exist on a spectrum that future studies may capture. This case emphasizes the importance of clinicopathologic correlation when EM, DRESS, or early SJS/TEN cannot entirely explain mucocutaneous morphology and when resolution occurs within 4 days following TMP-SMX exposure.