A patient with jaundice and a rash

A woman in her 60s presented with a three day history of jaundice and a migratory yellow pruritic rash. The rash was first noted on the inner part of both upper arms but quickly spread to the lower regions of the abdomen and back. The patient did not report any abdominal pain, change in urine or stool quality, fever, chills, or weight loss. She reported occasional cocaine use, with the last episode four days before admission. She used albuterol for asthma and omeprazole for gastro-oesophageal reflux disease. Physical examination showed diffuse, oedematous yellowish plaques with erythematous borders, localised to the upper arms (fig 1, left and middle panel) and lower back (fig 1, right panel). Initial blood tests showed raised levels of total bilirubin (171.0 μmol/L, normal range 0.0-20.5 μmol/L) and direct bilirubin/conjugated bilirubin (140.2 μmol/L, normal range 0.0-3.4 μmol/L), along with raised levels of aspartate aminotransferase (1146 U/L, normal …