MICHAEL E. MINGMD
An 18-year-old white woman with recurrent biphenotypic leukemia (acute myelogenous leukemia/acute lymphocytic leukemia) presented with neutropenic fevers after undergoing salvage chemotherapy. At presentation, her total white blood cell count was 0.4×103/μL (reference range, 4.0-10.5×103/μL). During her hospitalization, she developed a small-bowel obstruction and perforation, for which she underwent a small-bowel resection. Approximately 1 week later, a 1.5-cm flaccid bulla developed on the volar aspect of her right thumb, beneath her oxygen saturation monitor. In the following 24 hours, without any intervention, the lesion became necrotic with an enlarging eschar (Figure 1). Examination of a biopsy specimen, which was stained with periodic acid–Schiff (Figure 2) and methenamine silver, and microscopic examination of the resected necrotic bowel revealed similar findings.
O’Neill JT, Blair M, Graham BS. Necrotic Ulcer on the Thumb of a Teenager With Leukemia—Quiz Case. Arch Dermatol. 2005;141(5):633-638. doi:10.1001/archderm.141.5.633-g