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In daily medical practice, clinicians often make minor adjustments to a patient’s treatment plan, such as changing medications, updating dosages, or modifying administration methods. Most of the time, these changes improve symptoms and enhance quality of life. But sometimes, a routine adjustment can reveal something completely unexpected.

This was the case of a 55-year-old woman with chronic obstructive pulmonary disease (COPD). For years, her condition remained stable with her medications. Then, after switching to a new inhaler, she developed a rare and painful skin condition known as  Sweet’s syndrome  , a reaction so unusual that it may represent the first documented case related to inhaled therapy.

This story highlights why both patients and healthcare providers should remain alert to even subtle changes in the body, especially after medication adjustments.

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