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Dr. T. Rudra, Cardiff Royal Infirmary (West Wing), Newport Road, Cardiff CF2 1SZ (UK) Dear Sir, We report survival of a patient following a drug reaction to co-trimoxazole. The patient suffered acute tubular necrosis and bone marrow, liver and dermal involvement, including scrotal infarction. Although multisystem involvement [1] and interstitial nephritis are known, there has been only one previous report suggesting acute tubular necrosis [2]. Case Report A fit 78-year-old man was admitted with a clinical diagnosis of epididymo-orchitis and acute retention of urine. This was confirmed on examination and he also had benign prostatic hypertrophy. There was no significant past history apart from the occasional use of different nonsteroidal anti-inflammatory drugs for ‘backache’. A urinary catheter was inserted and he was commenced on flucloxacillin (500 mg/8 h) and cotrimoxazole (2 tablets/12 h). Initial investigations revealed normal electrolytes, blood urea 8 mmol/l (48 mg/dl) and serum creatinine 130 μmol/l (1.47 mg/dl). The haemoglobin was 155 g/l (15.5 g/dl), white cell count 10.6 × 10V1 (10,600 mm3) and platelet count 164xl0Vl (164,000/mm3). Urine microscopy and culture, and blood cultures were negative. Two days after admission he was noticed to have generalised erythema of the skin, particularly in the groins and inner aspect of the thighs and also extensive purple black discolouration of the scrotum. He was thought to be developing Fournier’s gangrene of the scrotum. Co-trimoxazole and ñucloxacillin were discontinued, and he was commenced on piperacillin and metronidazole. On the third day after admission it was noted that his urine output had fallen to 187 ml/24 h. Investigations showed a blood urea of 29.3 mmol/l (176 mg/dl), serum creatinine 507 μmol/l (5.74 mg/dl), serum Na+ 123 mmol/l (123 mEq/1) and K+ 4.5 mmol/l (4.5 mEq/1). There had been no impairment of haemodynamic status since admission, and he had received over 2 litres of fluid the previous 24 h. Renal ultrasound showed the right and left kidneys to measure 12.6 cm and 12.1 cm in length, respectively. There was no evidence of Fig. 1. Renal biopsy showing acute tubular necrosis. HE. obstructive uropathy. It was felt that the deterioration in renal function was drug-induced, and a renal biopsy was performed. This showed acute tubular necrosis (fig. 1). Fixation in absolute alcohol demonstrated no crystals. The skin rash extended without involving mucous membranes and the appearance was consistent with erythema multiforme. A skin biopsy was performed and did not show any evidence of