LAUSR

A 94-year-old woman presented to the acute medicine department with worsening confusion and a widespread erythematous rash. Her medical history included Alzheimer dementia and Paget disease, but she took no regular medication. Close physical examination of the patient’s skin revealed a widespread exfoliative dermatitis affecting most of her body surface area, with islands of sparing. The patient was suberythrodermic. There were areas of impetiginization and widespread excoriations, with no vesicles or targetoid lesions (Fig. 1). Her initial investigations demonstrated leucocytosis (17.8 9 10/L; normal range 4–11 9 10/L), eosinophilia (1.4 9 10/L; 0.04–0.4 9 10/L) and raised Creactive protein (101 mg/L; normal < 10 mg/L). The patient was prescribed regular emollients, oral antibiotics and a potent topical steroid; however, her skin showed only mild improvement and would quickly rebound when the topical steroid application was weaned. A skin biopsy was taken, and histological examination demonstrated spongiosis and neutrophils in the superficial epidermal layers. Within the dermis there was oedema and a perivascular inflammatory infiltrate consisting mainly of neutrophils and occasional eosinophils. Direct immunofluorescence was normal. Further review of the patient’s medication history did not identify any drug triggers. Meanwhile, collateral history given by family members revealed a history of weight loss, so investigations for an underlying malignancy were arranged. Computed tomography revealed a metallic density within the left upper abdomen. An upper gastrointestinal endoscopy, performed 4 weeks into the hospital stay, demonstrated an eroded British 10-pence coin, dated 2013, in the fundus of the stomach (Fig. 2). The coin was endoscopically removed using a Roth Net retriever. In view of this finding, urinary nickel levels were tested and found to be elevated at 84 600 nmol/L (nickel/creatinine ratio of 1226.1 nM/mM, normal < 19.0 nM/mM). Serum copper levels were normal. Based on these findings, a diagnosis of systemic contact dermatitis (SCD) caused by nickel ingestion was suspected. The patient’s skin condition quickly