It began quietly, without urgency or warning, the way many serious medical stories do. A 55-year-old woman walked into her primary care clinic with what appeared to be a routine dermatological complaint: painful red patches spreading across her cheeks and neck. There was no dramatic collapse, no respiratory distress, no immediate sign that anything was dangerously wrong. At first glance, it looked like a mild inflammatory skin reaction, perhaps an allergic flare or irritation. But the skin, as it turned out, was speaking long before the rest of the body had found its voice.
The patient had a complex but stable medical history. She had lived for years with chronic obstructive pulmonary disease, managed carefully through long-term inhaled therapy, and hypertension controlled with medication. She was a current smoker, averaging around ten cigarettes a day, a factor already well accounted for in her treatment plan. For six years, she had taken enalapril without complications. For two years, she had used inhaled formoterol with no adverse reactions. Nothing about her medical record suggested volatility or unexplained immune responses.
That changed when her COPD symptoms worsened.
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