A 24-year-old Indonesian man was admitted to the emergency room (ER) of a tertiary referral hospital on August 9, 2015 for erythematous macules on his entire body and a sore throat. Approximately one month earlier, he had been treated at several clinics for itching, fever, and myalgia, although these conditions did not improve. One week before the admission, his condition worsened and he developed rash with generalized edema and exfoliative dermatitis. He was alert when he arrived at the ER, with a blood pressure of 100/70 mmHg, a heart rate of 110/min, a respiratory rate of 20/min, and a body temperature of 39.1°C. The initial laboratory data revealed a white blood cell (WBC) count of 22,170/mm³ (segmented neutrophils: 32%, eosinophils: 36%, 7,910/mm³), a red blood cell count of 578/mm³, hemoglobin levels of 14.5 g/dL, hematocrit levels of 40.0%, a platelet count of 136,000/mm³, aspartate aminotransferase (AST) levels of 69 IU/L, and alanine aminotransferase (ALT) levels of 274 IU/L. The patient had a sore throat and exhibited erythema multiforme, desquamation, and generalized edema throughout his entire body (including the face and oral mucosa) (Fig. 1). It was not possible to obtain detailed medical or prescription histories, as he was a foreigner, although he notified staff that he had visited clinics before his admission. The medical staff suspected DRESS syndrome, based on his systemic symptoms with exfoliative dermatitis and elevated eosinophil levels, and treated the patient using hydration, antihistamine, and a topically applied steroid ointment.

On day 2 after the admission, the patient's body temperature increased to 39.6°C and did not drop below 37°C. Additional testing revealed a WBC count of 13,300/mm³ (eosinophils: 24.8%), AST levels of 102 IU/L, and ALT levels of 233 IU/L. Thus, the patient was treated using intravenous methylprednisolone (40 mg/day). Histopathologic examination of the skin biopsy revealed sub-epidermal cleft with bulla formation and vacuolar change in the basal layer (Fig. 1). Characteristic apoptotic keratinocytes and lymphocytic exocytosis were easily observed in the epidermis. There are upper dermal lymphocytic infiltration accompany with abundant extravasated erythrocytes. Also pigment incontinence was identified. And there is no evidence of viral infection. All these histopathologic findings were compatible with cutaneous drug-induced reaction. On day 3, the patient's body temperature remained at > 37°C, and he exhibited worsened skin symptoms with conjunctivitis. Intravenous cyclosporine treatment (250 mg) was initiated with prophylactic antibiotics. On day 4, the desquamation worsened and his body temperature remained at > 39°C. The systemic steroid was discontinued, and cyclosporine was administered with intravenous immunoglobulin. However, the patient lost consciousness at approximately 1 PM, and exhibited worsened vital signs (blood pressure: 80/60 mmHg, pulse: 140/min, respiration rate: 30/min, and body temperature: 39.8°C). Oxygen was administered using a reservoir mask, although his oxygen saturation was 94%. He began receiving intensive care at approximately 3 PM, experienced cardiac arrest at midnight, and did not respond to resuscitation.

To identify the occupation-related cause of death, an investigation of the patient's medical history was conducted, and statements were collected from colleagues at his work dormitory. The patient did not have a known medical history when he entered Korea in 2014. He performed polyester-related work for 6 months until March 2015, and was hired by a faucet manufacturer on June 25, 2015. He did not undergo a pre-placement medical examination or regular medical examinations when he joined the present industry. Employers are legally obliged to have their employees undergo a pre-placement medical examination when there is planned exposure to TCE during their work, and are also obliged to have them undergo a first regular health examination related to TCE exposure within six months of the pre-placement medical examination. It is unknown why these examinations did not take place. His TCE exposure resulted from soaking the product in a cleaning tank containing TCE during the electro-plating process. The electro-plating log revealed that he worked routinely each day between June 25 and July 17 in 2015, and he only completed 30 minutes of work and left during work hours on July 20. He subsequently worked on July 27 and 28 for each day. The TCE was frozen in a washing tub to prevent vaporization, and the cleaning process was performed under a ventilation hood. The company had completed air quality testing in the area around his ventilator space every 6 months, and the document revealed that TCE levels did not exceed the Korean permissible exposure limit (the 8-hour time-weighted average) of 10 ppm from 2013 to the first half of 2015. The time-weighted average values for TCE were 5.8224 ppm in July 2015 and 4.0556 ppm in December 2014. However, in the investigation for occupation-related cause of death, the 8-hour time-weighted average values for TCE were 6.294 and 14.770 ppm, respectively, and the maximum TCE concentration were 12.594 and 33.633 ppm, respectively.

According to his colleagues, the patient complained of whole-body itching, pain, and discomfort for weeks after starting the work. A subsequent investigation of his treatment history before the ER admission revealed that he had visited different clinics on July 13 and 14 because of persistent myalgia that had developed one week earlier. On July 13, Clinic A prescribed the patient oral talniflumate with streptokinase and tramadol (50 mg) injections. On July 14, Clinic B prescribed the patient oral acetaminophen, loxoprofen, and eperisone, with injections of a multi-vitamin (Pan-B-Comp; Daihan, Seoul, Korea) and tramadol (50 mg). It could not be verified whether he actually took the prescribed medications. His myalgia did not improve and he subsequently experienced new-onset systemic skin symptoms. He revisited Clinic A on July 20 and was prescribed prednisone, an antihistamine, and a dexamethasone injection (5 mg). On July 22, he revisited Clinic B and was prescribed an H2 blocker, an antihistamine, and prednisone. He took a one-week leave from work, although his systemic and skin symptoms worsened after returning to work on July 27 and 28. He subsequently visited Clinics B and C on August 1 and 3, although his condition continued to deteriorate and his colleagues subsequently brought him to the ER (Fig. 2).