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Immunocompromised patient with an ulcerated nasolabial skin lesion

BMJ 2010; 340 doi: http://dx.doi.org/10.1136/bmj.c1444 (Published 31 March 2010) Cite this as: BMJ 2010;340:c1444
  1. Emmanuel P Prokopakis, consultant,
  2. Irene E Panagiotaki, consultant,
  3. Ioannis A Papadakis, resident,
  4. Alexios S Vardouniotis, resident,
  5. George M Lagoudianakis, consultant,
  6. George A Velegrakis, professor
  1. 1Department of Otorhinolaryngology, University of Crete School of Medicine, Heraklion, Greece
  1. Correspondence to: I A Papadakis ioannispapadakis2003{at}yahoo.gr

    An 83 year old man was referred to us from the department of haematology because he had an exophytic and ulcerated nasolabial skin lesion. The lesion had been present for 6 months and caused severe facial pain, itching, foul odour, and dry eyes. The patient’s history included myelodysplastic syndrome, hypothyroidism, mild hypertension, mitral and aortic valve regurgitation, and paroxysmal atrial fibrillation.

    Physical examination revealed an extensive reddish and crusted nasolabial facial lesion that extended to the nasal cruses, causing left eyelid swelling and severe ectropion. The lesion was accompanied by some smaller lesions on the right mandible and cheek. The patient also had severe stenosis of the left nasal valve, which made nasal endoscopy particularly difficult. No enlarged cervical lymph nodes or other pathological physical findings were noted.

    Laboratory tests showed mild leucopenia (white blood cell count 3300 per μl), neutropenia (polymorphonuclear leukocyte count 900 per μl), and thrombopenia (platelet count 89 000 per μl), with normocytic and normochromic anaemia (haematocrit 27.3%, haemoglobin 8.3 g/dl, red blood cell count 2.8×103 per μl).

    Computed tomography revealed skin thickening of the anterior nose and maxilla, as well as opacity of the subcutaneous fat and increased iodine contrast intake, with no evidence of bone infiltration. The maxillary and ethmoid sinuses were congested by thick mucous secretions.

    The patient had received high doses of antibiotics in the department of haematology to treat his myelodysplastic syndrome; therefore, the facial lesion could have a possible infectious origin. The smear cultures from the lesion and the patient’s blood were negative for bacteria, parasites, and fungi.


    • 1 What is the most likely diagnosis?

    • 2 What are the differential …

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