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A 71-year-old woman with end-stage renal disease on hemodialysis, hypertension, diabetes, coronary artery disease, and ischemic cardiomyopathy, on hydralazine 300 mg daily for 2 years, presented with a new onset of vesiculobullous rash, dysphagia, odynophagia, throat pain/tightness, and hoarseness. Physical exam showed multiple vesicles in her upper and lower extremities with significant airway edema and ulcerations of floor of mouth, tongue, epiglottis, aryepiglottic folds, and arytenoid edema. On admission day 3, she had an episode of gastrointestinal bleeding. Upper endoscopy and capsule endoscopy found petechiae and melanosis in the proximal small bowel, including most of duodenum and proximal jejunum (Figure 1). Pathology revealed necrotizing neutrophil-rich venulitis and pseudomelanosis.