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July 2011

Tender Ulceronecrotic Nodules in a Patient With Leukemia —Diagnosis

Author Affiliations
 

SECTION EDITOR: MARY S. STONE, MD; ASSISTANT SECTION EDITORS: SOON BAHRAMI, MD; CARRIE ANN R. CUSACK, MD; SENAIT W. DYSON, MD; MOLLY A. HINSHAW, MD; ARNI K. KRISTJANSSON, MD

Arch Dermatol. 2011;147(7):857-862. doi:10.1001/archdermatol.2011.162-b

Histopathologic examination at low magnification showed zonal fat necrosis with associated dermal and subcutaneous suppurative inflammation and an intact epidermis. Careful examination of the necrotic areas at medium- and high-power magnification revealed numerous amebas with thick ruffed cell walls ranging from 15 to 40 μm in diameter around a medium-sized vessel. A periodic acid –Schiff stain (not shown) highlighted the cyst walls.

The patient was started on a regimen of flucytosine, sulfadiazine, pentamidine, and fluconazole. Magnetic resonance imaging of the brain showed no disease. All tissue cultures remained negative for organisms. Eight days after the diagnosis, treatment with miltefosine, an alkyl phospholipid compound with antiprotozoal activity, was begun. In addition to miltefosine, the patient was discharged on a regimen of flucytosine, sulfadiazine, and voriconazole. Three days into this regimen, she stopped developing new lesions. Seven weeks after discharge, her skin lesions were noted to be resolving, but because of a rapidly declining performance status owing to leukemia, she was transitioned to hospice care.

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