Endgames Picture Quiz

A rash in a patient with neutropenia

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8296 (Published 13 December 2012) Cite this as: BMJ 2012;345:e8296
  1. R T Woolf, specialist registrar dermatology1,
  2. T Yeghen, consultant haematologist2,
  3. H du P Menagé, consultant dermatologist1
  1. 1Department of Dermatology, University Hospital Lewisham, Lewisham Healthcare NHS Trust, London SE13 6LH, UK
  2. 2Department of Haematology, University Hospital Lewisham
  1. Correspondence to: R Woolf richard.woolf{at}kcl.ac.uk

A 72 year old man with relapsed acute myeloid leukaemia developed a rash seven days after starting a combined chemotherapy regimen (fludarabine, cytarabine, granulocyte colony stimulating factor, and idarubicin). He first noticed a painful lesion on his left forefoot, and over the next seven days he developed similar lesions on the left lower limb (fig 1), right thigh, and face. He was referred for a dermatological opinion on day 14.

He was pancytopenic, with undetectable neutrophils and lymphocytes. No prophylactic antibacterial or antifungal drugs had been given. On the fifth day after chemotherapy he had developed a fever with new consolidation on chest radiography. He had been started on empirical broad spectrum antibiotics (piperacillin-tazobactam and gentamicin, with the addition of teicoplanin on day 10 owing to meticillin resistant Staphylococcus aureus being cultured in sputum). Despite this, he remained febrile, with worsening inflammatory markers (C reactive protein 270 mg/L; reference range <5 mg/L; 1 mg/L=9.52 nmol/L) and was being managed in an isolation room. He was otherwise asymptomatic and remained stable from a cardiovascular point of view. Chest computed tomography on day 14 showed bilateral multifocal consolidation with faint peripheral halos.

Questions

  • 1 How would you describe the morphology of the presenting rash?

  • 2 What is the most likely diagnosis?

  • 3 What would you consider in your differential diagnosis?

  • 4 What additional diagnostic investigations could you consider?

  • 5 How would you treat this patient?

Answers

1 How would you describe the morphology of the presenting rash?

Short answer

There are two annular macular erythematous lesions overlying the left knee. The largest is about 3 cm in diameter and has a dusky necrotic centre. The smaller 1 cm lesion also has a darker centre.

Long answer

Overlying the left knee there are two annular macular erythematous lesions. The largest measures about 3 cm in diameter and has a dusky necrotic centre. The smaller 1 cm lesion also has …

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