Day 1: Patient Assessment
A 53-year-old Caucasian male presents to the Emergency Department for evaluation of a painful rash on his bilateral lower extremities. He believes the eruption started two months prior, around the time he adopted two stray kitchens which he notes, “like to scratch him.” At that time, the lesions appeared as mildly erythematous, linear scrapes for which his primary care provider prescribed clindamycin 300 mg four times daily. The patient recalls some resolution of the erythema with this regimen; however, the eruption never fully cleared. Over the past two weeks, he notes the rash evolved from linear scratches to raised pustules, and ultimately to round, ulcerative lesions with “black spots.” The patient reports “digging out” pustules using “needles” which elicited drainage of white and clear fluid. During this time the lesions have spread proximally from his ankles and lower legs to the level of his knees with few scattered papules on his arms, bilaterally. At its worst, he notes pain has been 10/10 in severity. In addition to pain, a review of symptoms is positive for itching, nausea, vomiting, sore throat, and wheezing. He denies any burning sensation, shortness of breath, joint pain, urinary symptoms, and fever.
Past medical history is significant for asthma and substance use disorder. The patient also notes “bad teeth” for which he has undergone numerous dental procedures with the most recent being one month ago. He is unsure if his tetanus vaccination is up to date. Medications include Albuterol, Advair, and Suboxone sublingual tablets. He has no known drug or environmental allergies. Social history is positive for occasional alcohol consumption, a 30-year history of chewing tobacco, and 15 years of methamphetamine use. Family history is negative for autoimmune disease, cancer, or chronic conditions.
Physical exam reveals numerous circular, 2-10 mm papules and few 5-40 mm ulcers with central necrosis scattered across the shins, calves, and ankles bilaterally (Figure 1). Papules do not blanch upon pressure. Non-pitting edema can be seen on the lower legs in addition to some dry scale of the plantar feet. Further examination reveals approximately 10-20 red papules ranging from 2-6 mm in size on the bilateral wrists and forearms which are not necrotic. The patient’s vital signs are within normal limits, including a temperature of 98.3 °F and oxygen saturation of 98% on room air. Examination of the head, neck, chest, and abdomen is unremarkable.
The patient is admitted to observation and an initial workup is begun. Chest X-ray is negative for any obvious pulmonary causes of his reported wheezing. Lab draws are remarkable for eosinophilia (12.4 x 109/L, ref < 0.5 x 109/L) elevated ESR (27 mm/hr, ref 1-13 mm/hr) and elevated CRP (1.7 mg/dL, ref < 1.0 mg/dL). Serial blood cultures are ordered to rule out bacteremia and endocarditis due to the patient’s history of invasive dental procedures and illicit drug use. The patient is started on empiric antibiotic therapy with vancomycin and levofloxacin. Infectious disease is consulted.