| Introduction: |
| A 37-year-old man with myelodysplastic syndrome was evaluated for painful nodules that erupted one day earlier on the extremities. |
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| History: |
| The patient had a 3-day history of fever, chills, and nause but denied chest pain or shortness of breath. At the time of admission blood cultures were sent, and he was started on parenteral antibiotics including vancomycin, gentamicin, and cefepime. However, symptoms rapidly progressed. |
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| Clinical
Presentation: |
| Physical examination revealed an ill-appearing, diaphoretic man in moderate distress with multiple erythematous, tender nodules on both legs and the top of the left hand. He also had an ill defined, annular, plaque on the right leg. |
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| Pathology: |
| A 4 mm skin punch biopsy of a nodule on the leg revealed a neutrophilic lobular panniculitis. An intense inflammatory infiltrate was present at the dermal-subcutaneous interface and in the adipose tissue in an interstitial pattern. Inflammatory infiltrates outlined the individual adipocytes giving a lacy pattern pattern. Special stains for organisms including PAS, acid fast, Gram-Weigert, and Brown and Hopps were negative. |
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| Question
1: |
| What is the differiential diagnosis in this setting? |
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| Question
2: |
| What further historical information would be helpful? |
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| Question
3: |
| What further laboratory information will help confirm your working diagnosis? |
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| Question
4: |
| How would you treat him? |
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