A rare case of Non-lupus full house nephropathy in a transplanted kidney, case report:Ahmad Matarneh(1), Omar Salameh(2), Sundus Sardar(1), Amanda Karasinski(1), Theja Channapragada(2), Muhammad Abdulbasit(1), Erik Washburn(3), , Nasrollah Ghahramani(1)Affiliations: 1. Department of nephrology, Penn state Milton S Hershey Medical Center, United States of America2. Department of Internal Medicine, Penn state Milton S Hershey Medical Center, United States of America3. Department of pathology, Penn state Milton S Hershey Medical Center, United States of AmericaCorresponding authorAhmad MatarnehAffiliation: Penn State health , Milton S.hershey medical centerContact: Email [email protected] # 717-708-6754Keywords:Autoimmune disorders, Systemic lupus erythematosus, Transplant rejection. Full house nephropathyAbstract:Non lupus full house nephropathy is a rare entity with an unclear incidence. It describes the kidney biopsy findings of positive deposits for IgG, IgA, IgM, C3, C1q on immunofluorescence in the absence of the classical diagnostic features of systemic lupus nephritis. This disease entity is becoming more recognised but further studies are still needed to evaluate the incidence, etiologies and management of this condition. Transplant glomerulopathy is a major cause for renal graft loss. It can present with a wide variety of manifestations; It can cause AKI, CKD or glomerular inflammations through an immune complex or autoimmune mediated damage.Introduction:Non lupus full house nephropathy is defined as having the classical findings of lupus nephritis which are positive deposits for IgG, IgA, IgM, C3, C1q on immunofluorescence but without the other extra-renal or seologic manifestations needed for SLE diagnosis i.e ACR criteria.(1) Systemic lupus erythematosus is a multi-system autoimmune disorder. It can involve several organs with variable presentations. The diagnosis of SLE is mainly based on establishing the presence of >= 4 points of the American College of Rheumatology criteria. (2) Lupus nephritis is the renal manifestation of SLE, it can have a wide range of manifestations which can include AKI, nephrotic or nephritic syndrome secondary to glomerulonephritis or it can ultimately lead to ESRD. Kidney biopsy remains the gold standard test to diagnose and to guide the treatment of lupus nephritis. Classical kidney involvement in SLE is based mainly on the pattern of histological involvement and it is divided into several classes according to the international society of nephrology. (3) Transplant rejection remains a huge challenge to both patients and treating physicians, it can result in variable degree of kidney dysfunction and ultimately it might lead to graft loss.(4) Several risk factors for transplant rejection have been described in literature and certainly, autoimmune diseases remain high on the list.(5) We hereby report a patient who presented with nephrotic syndrome and was found to have de-novo non lupus full house nephropathy in the transplanted kidney.Case presentation: Patient is a 57-year-old female with a past medical history of End-Stage Renal Disease that was managed with a living unrelated kidney transplant in 2016, Hypothyroidism, and Type 1 Diabetes Mellitus (T1DM) managed with an insulin pump. The patient underwent a living unrelated kidney transplant in 2016 with significant post-transplant complications with ureteral strictures. Initially, she was managed by nephrostomy followed by multiple indwelling stent exchanges. However, stents were repeatedly colonized with multiple bacterial and candida infections, requiring antibiotic and antifungal therapy. Due to recurrent acute infections mycophenolate mofetil was held and she had a stent removal in an attempt to decrease her risk of UTI’s.She presented to an outside hospital with a 1-week history of progressively worsening generalized headaches, nausea/vomiting, and elevated home blood pressures. Her blood pressure was noted to be 200/120. Initial labs were notable for hemoglobin of 8.5g/dl, blood urea nitrogen (BUN) of 82 mg/dL, and creatinine of 3.35mg/dL, with baseline creatinine 2.2-2.5mg/dL.Physical exam on presentation was significant for +1 lower extremity edema, with the remainder of the physical exam within normal limits, Patient was afebrile and BP was noted to be 171/81 mmHg.Investigations:Labs notable for potassium 6.1 mEq/L, chloride 116 mEq/L, bicarbonate 18 mmol/L, blood urea nitrogen (BUN) 82 mg/dL, creatinine 3.64 mg/dL, phosphorus 6.0 mg/dL, hemoglobin 8.7 g/dl, and platelets 148. VBG showed pH 7.240, PCO2 41, PO2 42, bicarbonate 17.6. Blood, urine, and fungal cultures were normal. A urine protein/creatinine (PCR) ratio was 12.74, consistent with nephrotic range proteinuria. (Table 1)Table 1. Laboratory investigations.Ultrasound retroperitoneal revealed hydronephrosis in the right lower quadrant, transplant kidney with urothelial and collecting system thickening, stable from the previous ultrasound one month prior. Given the patient’s history of prior urethral stricture, however, she had a right ureteral stent placed with the urology team. Following stent placement, however, the patient’s urine output was less than 200cc, and her creatinine rose to 3.9.An additional renal ultrasound with doppler was done to evaluate blood flow through the transplanted kidney, revealing increased renal artery resistive indices of 0.93 and associated high resistance arterial waveform, concerning for chronic rejection. While CMV/BK and donor-specific antibiotics were negative, Further immunological workup was done revealing positive Antinuclear Antibody (ANA) but negative anti-double stranded DNA (anti-dsDNA) and anti-smith antibody (Sm). C3 was borderline low and C4 was normal. Additional workup for membranoproliferative glomerulonephritis, including hepatitis B and C serologies, were negative. there were still concerns about rejection, and the patient underwent a renal biopsy with interventional radiology. The preliminary read from the biopsy was concerning T-cell kidney transplant rejection versus membranoproliferative glomerulonephritis versus lupus nephritis.The final read of the biopsy demonstrated membranoproliferative glomerulopathy, immune complex-mediated with rare cellular crescents, and foci of fibrinoid necrosis. The full-house immunofluorescence staining suggests lupus nephritis as a possible etiology. Mild tubulitis and interstitial mononuclear inflammation meet the criteria for borderline/suspicious for acute T-cell mediated rejection. (Figures 1-5)She was diagnosed as a case of chronic rejection with immune complex deposition disease. She was treated with 1 gram of intravenous methylprednisolone once and transitioned to 60 mg oral prednisone once daily throughout the remainder of the course and at discharge. Her BUN continued to rise in the setting of steroid use, as high as 178 mg/dL at discharge.. In addition, patient developed hypoalbuminemia with associated anasarca. Her anasarca was managed with a bumetanide drip that was transitioned to intermittent dosing of 2 mg bumetanide on discharge. The patient’s urine output increased to over 1L with diuretics, with creatinine levels down trending. On discharge, the patient’s creatinine was 2.98 mg/dL.Outcome:The patient was followed up in the transplant nephrology clinic two weeks after discharge. Creatinine improved to 2.63 mg/dL. Proteinuria decreased to 5.7 with a 50% reduction from hospital admission. Patient’s lower extremity swelling decreased significantly. She was maintained on tacrolimus 2 mg twice daily, MMF 500 mg twice daily. Given the biopsy findings and her improvement of her creatinine and proteinuria degree it was decided to continue treatment as an underlying chronic rejection.Discussion: Glomerulonephritis remains one of the leading causes of renal graft loss following kidney transplant.(6) The incidence is widely variable and differs between studies. Recurrent and de-novo glomerulonephritis following kidney transplant are not uncommon and have been described as a cause of renal graft loss and/or dysfunction. Recurrence of GN is typically more common than de-novo processes.(7) GN is one of the main causes of renal graft loss after kidney transplant, according to one of the studies it was noted that recurrence of GN was the third most common cause of renal graft loss. (8) De-novo disease is defined as any new disease process that occurs in the kidney graft unrelated to the primary kidney disease. De-novo disease can have a variable presentation as it can manifest as acute, subacute to chronic with manifestations usually arising from glomerulonephritis, tubulointerstitial nephritis or vascular disease. The incidence of de-novo GN is unclear and has been hypothesized to be occurring in 4-20% of transplant recipients.(9) Most common patterns of GN are FSGS, MGN, MPGN. (10) Transplant glomerulopathy remains one of the major debilitating conditions that transplant patients deal with. It can present with a chronic or acute rejection picture in the form of steady rise in creatinine and GN pattern of injury. (11) Systemic lupus nephritis is a chronic inflammatory autoimmune condition that can affect multiple organs with variable presentations. Diagnosis is usually based on the classical serologic and extra renal criteria. (12)Lupus nephritis is one of the serious manifestations of SLE, it is defined as the presence of significant proteinuria and classical findings on kidney biopsy. Classical kidney biopsy findings of lupus nephritis under light microscopy are I. minimal mesangial, II. Proliferative mesangial, III. Focal proliferative, IV. Diffuse proliferative, V. membranous and VI. Sclerosing. One of the relatively specific findings on direct immunofluorescence on kidney biopsy is finding deposits positive for IgG, IgA, IgM, C3 and C1q, a pattern that is usually referred to as the full house pattern. (13) This finding is relatively specific for lupus nephritis however, in order to establish the diagnosis of SLE, the ACR criteria must be met.(14) Non lupus nephritis describes the classical IF findings of LN but without the clinical or serological evidence of lupus. It is a newly developing entity and that means further studies are still needed to better understand the incidence and its exact pathophysiology and presentations. (15)Kidney transplant remains the gold standard treatment for ESRD. It has shown to improve both quality of life and survival in comparison to renal replacement therapies. (16) Transplant rejection occurs as a result of the body’s own immune system creating antibodies against the alloantigen from the transplanted kidney. (17) The response can be variable in intensity and onset, it ranges from hyperacute which can happen within minutes of transplant and is usually related to preformed antibodies or ABO mismatch. Acute rejection occurs any time following transplant and is subclassified depending on the underlying factor and immune mechanism to antibody mediated rejection (ABMR), which usually happens as a result of donor specific alloantibodies damaging the kidney causing peritubulitis/capillaritis. And acute T-cell mediated rejection (TCMR_ which is characterized by lymphocytic infiltrate into tubules, interstitium and arterial intima. Chronic rejection on the other hand usually occurs after 3 months and can be as a result of chronic T cell mediated or chronic antibody mediated. (18)Risk factors for transplant rejection include: HLA mismatch, Positive B cell crossmatchAdvanced age of the donor type of transplant and inadequate immunosuppression. (19) Patients with rejection present differently, any increase in creatinine more than 25% of the baseline or the presence / worsening of proteinuria should raise the suspicion for rejection. Kidney biopsy might be warranted if transplant rejection is suspected as it would guide the management and further prognosis. (20)There has been no cases in literature describing the presence of non-lupus-full house nephropathy in the setting of post kidney transplant, we hypothesize that it might be related to circulating immune complex mediated damage to the transplant kidney possibly in the setting of chronic rejection. The point of interest in this condition and in our case in particular is that the patient was treated mainly for the possible underlying rejection with resuming mycophenolate and optimizing tacrolimus with institution steroids which lead to improvement in her kidney parameters and more than 50% drop in the degree of proteinuria. This further suggests that the possible underlying mechanism is related to the rejection process causing the non lupus pattern and nephrotic syndrome.Conclusion: Non lupus full house nephropathy is rare and is poorly understood. It has been described in association to several conditions however, There has been no data describing the associated post kidney transplant and rejection. Non lupus full house nephropathy can occur in the setting of kidney transplant and it might be related to transplant rejection. We wanted to raise awareness about this condition and possible association in transplant recipients as it carried out a worse prognosis and can lead to loss of graft function, also, to describe the methods in the diagnosis and a proposed treatment regimen.References:• Silva MD, Oliveira PV, Vale PH, Cunha RD, Lages JS, Brito DJ, Salgado Filho N, Guedes FL, Silva GE, Santos RF. Non-lupus full-house nephropathy: a case series. Brazilian Journal of Nephrology. 2020 Nov 11;43:586-90. • Mok CC, Lau CS. Pathogenesis of systemic lupus erythematosus. Journal of clinical pathology. 2003 Jul;56(7):481. • Ayoub I, Cassol C, Almaani S, Rovin B, Parikh SV. The kidney biopsy in systemic lupus erythematosus: a view of the past and a vision of the future. Advances in chronic kidney disease. 2019 Sep 1;26(5):360-8. • Vaillant AA, Mohseni M. Chronic Transplantation Rejection. InStatPearls [Internet] 2023 Jan 1. StatPearls Publishing. • Neuberger J. Incidence, timing, and risk factors for acute and chronic rejection. Liver transplantation and surgery: official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 1999 Jul 1;5(4 Suppl 1):S30-6. •Allen PJ, Chadban SJ, Craig JC, Lim WH, Allen RD, Clayton PA, Teixeira-Pinto A, Wong G. Recurrent glomerulonephritis after kidney transplantation: risk factors and allograft outcomes. Kidney international. 2017 Aug 1;92(2):461-9.• • Jafari R, Mehrazma M, Vahedi M, Ossareh S. Prevalence and Prognosis of Post-transplant Glomerulonephritis in Kidney Transplant Biopsies, A Single-Center Report. Iranian Journal of Kidney Diseases. 2023 Mar 1;17(2):92. • Briganti EM, Russ GR, McNeil JJ, Atkins RC, Chadban SJ. Risk of renal allograft loss from recurrent glomerulonephritis. New England Journal of Medicine. 2002 Jul 11;347(2):103-9. • Abbas F, El Kossi M, Jin JK, Sharma A, Halawa A. De novo glomerular diseases after renal transplantation: How is it different from recurrent glomerular diseases?. World Journal of Transplantation. 2017 Dec 12;7(6):285. • Hariharan S, Adams MB, Brennan DC, Davis CL, First MR, Johnson CP, Ouseph R, Peddi VR, Pelz CJ, Roza AM, Vincenti F. RECURRENT AND DE NOVO GLOMERULAR DISEASE AFTER RENAL TRANSPLANTATION: A Report from Renal Allograft Disease Registry (RADR): 1, 2. Transplantation. 1999 Sep 15;68(5):635-41. • Filippone EJ, McCue PA, Farber JL. Transplant glomerulopathy. Modern Pathology. 2018 Feb 1;31(2):235-52. • Gill JM, Quisel AM, Rocca PV, Walters DT. Diagnosis of systemic lupus erythematosus. American family physician. 2003 Dec 1;68(11):2179-87. • Musa R, Brent LH, Qurie A. Lupus nephritis. • Anders HJ, Saxena R, Zhao MH, Parodis I, Salmon JE, Mohan C. Lupus nephritis. Nature reviews Disease primers. 2020 Jan 23;6(1):7. • Wani AS, Zahir Z, Gupta A, Agrawal V. Clinicopathological pattern of non-lupus full house nephropathy. Indian Journal of Nephrology. 2020 Sep;30(5):301. • Braun MM, Khayat M. Kidney Disease: End-Stage Renal Disease. FP essentials. 2021 Oct 1;509:26-32. • Halloran PF, Einecke G, Sikosana ML, Madill-Thomsen K. The biology and molecular basis of organ transplant rejection. InPharmacology of Immunosuppression 2022 Jan 29 (pp. 1-26). Cham: Springer International Publishing. • Wood KJ, Goto R. Mechanisms of rejection: current perspectives. Transplantation. 2012 Jan 15;93(1):1-0. • Oweira H, Ramouz A, Ghamarnejad O, Khajeh E, Ali-Hasan-Al-Saegh S, Nikbakhsh R, Reißfelder C, Rahbari N, Mehrabi A, Sadeghi M. Risk factors of rejection in renal transplant recipients: a narrative review. Journal of Clinical Medicine. 2022 Mar 3;11(5):1392. • Williams WW, Taheri D, Tolkoff-Rubin N, Colvin RB. Clinical role of the renal transplant biopsy. Nature Reviews Nephrology. 2012 Feb;8(2):110-21.Acknowledgments: We thank the nephrology department at penn state health for giving us the opportunity and support to conduct this workAuthor contribution: Ahmad Matarneh: Manuscript writing, literature review, Clinical careOmar salameh Manuscript writing, literature review, Clinical careSundus sardar Manuscript writing, literature review, Clinical careTheja Channapragada Manuscript writing, literature review, Clinical careMohammad Abdulbasit Manuscript writing, literature review, Clinical careAmanda Karasinsk iManuscript writing, literature review, Clinical careErik Washburn HistopathologyNasrollah ghahramani: Clinical care, literature review, manuscript write up, MentorConsent: Verbal informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policyConflict of interest The authors associated with the this case report have no actual or possible conflict of interest to declareDate availability statement: The data that support the findings of this study are available on request from the corresponding authorFunding: The funding process is solely done from the writing authors

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Systemic Lupus Erythematosus Associated with Erythema Multiforme : A Rare Case Report of Rowell’s Syndrome

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First-trimester exposure to tofacitinib in ulcerative colitis: A case report of a healthy newborn and literature reviewArteen Arzivian1,2, Eva Zhang1, Robyn Laube1, Rupert Leong1,21 Department of Gastroenterology and Hepatology, Macquarie University Hospital, Sydney, Australia.2Faculty of Medicine, Health and Human Sciences, Macquarie Medical School, Macquarie University, Sydney, NSW, Australia.

Chronic inflammatory demyelinating polyneuropathy. A case descriptionGarcia-Castillo M.Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.

Evaluation of flow dynamics in dSINE (distal Stent graft-induced New Entry) using 4D flow MRIKenji Sakakibara1), Hiroyuki Nakajima1), Yudai Hagihara1), Chie Nakamura1), Daichi Shikata1), Yuki Takesue1), Satoru Shiraiwa1),Yoshihiro Honda1),Shigeaki Kaga1)Masahiro Hamasaki2), Hisashi Johno2)1) Department of Surgery (II), Faculty of Medicine, University of Yamanashi2) Department of Radiology, Faculty of Medicine, University of Yamanashi

A Symphony of Anomalies: Isolated Pulmonary Artery Agenesis Meets Congenital Lung HypoplasiaNida Ansari, D.O.1, Sacide S. Ozgur, M.D.1, Alan Alcantara, M.D.1, Yasmeen Sultana, M.D.1Disclosure of Interest: The authors report no conflict of interest. An ethical review is not necessary because this is a case report. This research received no specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Consent: As this is a case report, consent was obtained for the purpose of this paper.Acknowledgments: We would like to acknowledge the patient and his family for allowing us to share this case with our colleagues.Author affiliation: Ansari, N, Ozgur, S, Alcantara, A, performed the literature review and wrote the manuscript, and all authors contributed to the writing, the final editing, and the collection of the patient’s clinical data. All work was performed at St. Joseph’s University Medical Center at the following address:St. Joseph’s University Medical Center Department of Internal Medicine 703 Main Street Paterson, NJ USA 07503 973-754-2000All authors, including the corresponding author, may be reached using the aforementioned contact information.

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Key Clinical MessageSturge–Weber syndrome (SWS) is a neurocutaneous syndrome characterized by angiomas. This report presents airway management using submental intubation in sagittal split ramus osteotomy under general anesthesia and aimed to explore better anesthetic management for avoiding the rupture of angiomas in a patient with SWS.

EBV-associated CNS Infection in an Immunocompetent Adult: A Case Report and Literature ReviewGwyn Srifuengfung, MD1, Pichatorn Suppakitjanusant, MD1, Nattanicha Chaisrimaneepan, MD21Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, TX, USA2Department of Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USACorresponding author: Nattanicha Chaisrimaneepan, MDDepartment of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock, TX, USA3601 4th St, Lubbock, TX 79430Email: [email protected]: All the authors declare no conflict of interest.Verbal and written consent was obtained from the patient to publish his case.AbstractEpstein-Barr virus (EBV) infections typically manifest with respiratory symptoms, lymphadenopathy, and, rarely, central nervous system (CNS) involvement. We report an uncommon case of an immunocompetent 18-year-old male with altered mental status due to EBV-associated CNS infection. The patient, with a recent history of infectious mononucleosis, presented with fever and meningeal irritation signs. Initial investigations revealed leukocytosis, atypical lymphocytes, and positive heterophile antibodies, but a head CT scan was normal. Empirical treatment for bacterial meningitis was initiated. Results of further assessments, including a positive EBV serology, a consistent cerebrospinal fluid analysis and positive EBV DNA in the CSF led to the diagnosis of EBV-associated CNS infection-more specifically meningoencephalitis. Neuroimaging, including MRI, showed no abnormalities. The patient improved with supportive care and a four-day course of acyclovir. We discussed the challenges in diagnosing EBV-associated CNS infection, emphasizing the role of CSF PCR in confirming the diagnosis. The importance of ruling out other infections is highlighted, and the heterogeneity in the mechanism of infection is explored. The case underscores the significance of recognizing an isolated, active EBV infection in young adults with altered mental status, especially when more common causes have been excluded.Keywords: Epstein-Barr virus, CNS infection, aseptic meningitis, altered mental status, CSF PCR, viral encephalitis.

Leukemia cutis revealing relapse of a chronic myeloid leukemia: a case report

IntroductionCoronavirus disease 2019 (COVID-19) is a highly contagious respiratory illness caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The virus was first identified in Wuhan, China in December 2019 and has since spread globally, leading to a worldwide pandemic. The majority of individuals who contract COVID-19 experience mild to moderate symptoms and recover within a few weeks. However, a significant proportion of individuals continue to experience symptoms long after the acute phase of the illness has resolved, a condition known as Long-COVID or post-acute sequelae of SARS-CoV-2 infection (PASC).1 Long-COVID symptoms can be diverse and can range from mild to severe, and can include fatigue, depression, anxiety, joint pain, headaches, and cognitive impairment.There are currently no effective or broad treatment options for Long COVID, but some symptom-related management has been trialed. Traditional treatment options, including rehabilitation, physical therapy, and medications, may not be fully effective for all individuals.2 The pathophysiology of Long-COVID is still being elucidated and there is a need for alternative treatment options. A recent review has suggested that psilocybin and 3,4-Methyl​enedioxy​methamphetamine (MDMA) may be an effective treatment option for the mental health challenges associated with COVID.3 Psychedelics have been traditionally used in spiritual and religious practices, but in recent years, there has been a resurgence of research on the therapeutic potential of psychedelics.4 Psychedelics have shown promise in the treatment of various medical conditions such as depression, anxiety, PTSD, and addiction.4 This case report describes the experience of a 44-year-old female who developed Long-COVID symptoms after contracting COVID-19 and her experience managing her symptoms and using psychedelics as a treatment. To our knowledge, this is the first case report describing the potential efficacy of psychedelics for Long-COVID symptoms.

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”Waldmann’s Disease: Primary Intestinal Lymphangiectasia Diagnosed by 99mTc-labeled Albumin Macroaggregate Scintigraphy - A Case Report in an Adult Patient.”Alex Castellón Méndez A1, Allan Bodán Campbell A1, Mohammed Zahran1, Victor Rosales Obregón2.Department of Internal Medicine, Manolo Morales Peralta Hospital, Managua, Nicaragua.Department of Nuclear Medicine, Nora Astorga National Radiotherapy Center, Managua, Nicaragua.

Ibuprofen Unveiled: A Middle-Aged Odyssey through Stevens-Johnson SyndromeAhmed Qasim Mohammed Alhatemi1, Hashim Talib Hashim2, Mohammed Abdul Rahman 3, Rand K Abdulhussain 4. Ali Talib Hashim5.Al Nasiriyah Teaching Hospital, Thi Qar, [email protected] Al Anbiyaa university, Karbala, [email protected] Nasiriyah Teaching Hospital, Thi Qar, [email protected] of Huddersfield, Huddersfield, [email protected] University of medical sciences, Gorgan, [email protected]*Corresponding Author: Ali Talib Hashim, Golestan University of medical sciences, Gorgan,[email protected] statement: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policyWe declare that we have no conflict of interestNo source of funding receiveData availability statement The data that support the findings of this study are available from the corresponding author upon reasonable request.Clinical key messageIbuprofen, a common NSAID, may unravel unexpected dangers like Stevens-Johnson Syndrome. This case underscores the urgency of recognizing adverse drug reactions, urging vigilance in both healthcare and public spheres for safer medication practices.Introduction:Ibuprofen, a widely used nonsteroidal anti-inflammatory drug (NSAID), has long been a stalwart in the realm of pain relief and inflammation management. However, behind its commonplace presence in medicine cabinets, there lies a potential peril that, though rare, demands our attention and understanding. This narrative unfolds as a middle-aged individual embarks on an unexpected journey through the harrowing landscape of Stevens-Johnson Syndrome (SJS) – a severe and, at times, life-threatening skin disorder (1,2). As the story begins, it beckons us to consider the seemingly innocuous act of reaching for an over-the-counter pain reliever. In this case, ibuprofen serves as the unwitting protagonist, a common choice for those grappling with the discomforts of everyday ailments (3). The unsuspecting middle-aged protagonist, seeking respite from a routine headache or muscular ache, unwittingly triggers a chain of events that will unfold into a rare and alarming medical ordeal (4). Stevens-Johnson Syndrome, characterized by the abrupt onset of a painful rash and blistering, often involves the mucous membranes, including the eyes, nose, and mouth. It can be triggered by various medications, and ibuprofen, despite its ubiquity and perceived safety, is not exempt from this list (5). The narrative explores the unfolding symptoms, the perplexing escalation from mild discomfort to severe skin involvement, and the subsequent medical odyssey that ensues (5). This exploration delves into the broader implications of drug safety, shedding light on the delicate balance between the benefits and risks of widely used medications. It underscores the importance of vigilance, both on the part of healthcare providers and the public, in recognizing potential adverse reactions (6). Through this journey, we navigate the intricacies of drug-induced skin disorders and the critical role of prompt medical intervention in steering the narrative towards recovery (7). ”Ibuprofen Unveiled” invites readers to contemplate the uncharted territories that can emerge from seemingly routine decisions and prompts a reconsideration of our relationship with common medications that weave seamlessly into the fabric of our daily lives.KeywordsAcute medicine, Dermatology, Immunology, Critical care medicine, pharmacology and pharmacy.Case presentationA middle-aged female presented to the emergency room with a sudden onset of severe facial swelling, red painful eyes with discharge, crusting and erosion of lips, and a generalized non-blanching purpuric rash, predominantly on the chest, upper, and lower limbs. Upon thorough history-taking, it was revealed that she had taken ibuprofen for flu-like symptoms three days prior. She had no past medical history of chronic diseases and was not taking any medications. She is a non-smoker and non-drinker. During examination, the patient, an average-built female, appeared in distress but was fully conscious, oriented to time, place, and person. Cardiac, respiratory, and neurological examinations were unremarkable. Her vital signs were as follows: BP 133/88 mmHg, RR 22, SpO2 95%, HR 88 bpm, and a temperature of 38.4°C. Head, neck, and eye examination revealed conjunctivitis with discharge, coalescing deep red erythematous targeted macules with central blister formation on the face, and swelling, erosion, and yellowish discharge of the lips (chelitis) as depicted in figure 1.

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