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+A 45-year-old lady sought dermatology consultation for severely tender erythematous vesicles and bullae over back, chest and arms.
+These were sudden in onset associated with fever, nausea and malaise.
+Along with this she also complained of pain in upper abdomen.
+There was no history of receiving any drugs prior to the onset of lesions.
+She did not report any significant weight loss or loss of appetite.
+On physical examination, her temperature was 38°C, pulse rate was 100/min and blood pressure was 126/72 mm Hg.
+There were multiple coalescing vesicles and bullae over upper back, chest and arms distributed symmetrically showing areas of pustulation and necrosis.
+Surrounding them were multiple pseudovesicular satellite papule (figure 1A,B).
+On per abdominal examination mild tenderness was present in the right hypochondrium.
+Patient's initial laboratory investigations showed a total leucocyte count of 12 000 cells/mm3 with 75% neutrophils.
+The haemoglobin level was 14.3 gm% and erythrocyte sedimentation rate was 30 mm/h.
+Liver function test, kidney function test and C reactive protein levels were within normal limits.
+Gram stain from purulent exudates showed only neutrophils without any organisms and culture did not show any growth after 72 h of incubation.
+A lesional skin biopsy taken from the satellite papule showed neutrophilic infiltration in dermis with papillary dermal oedema and spongiosis (figure 2A,B).
+Abdominal ultrasonography revealed intraluminal gall bladder mass suggestive of malignancy.
+On the basis of these findings a final diagnosis of SS associated with gall bladder malignancy was made.
+She was started on oral prednisolone in dose of 40 mg daily along with symptomatic treatment.
+Her cutaneous lesions responded dramatically and subsided completely after 1 week of treatment (figure 3A,B).
+Dose of prednisolone was tapered and an open cholecystectomy was performed.
+Histopathology of excised tissue confirmed it to be well-differentiated gall bladder adenocarcinoma forming glands and papillae infiltrating the muscularis propria superficially.
+Cystic duct cut margins were free of tumour (figure 2C,D).
+Patient's postoperative period was uneventful and she was discharged on tapering doses of prednisolone with advice to follow-up periodically.