Punch biopsy specimens from multiple affected areas of the patient's skin demonstrated similar histologic findings. Hematoxylin-eosin–stained sections revealed significant and extensive necrosis involving the reticular dermis and subcutaneous tissue. On higher-power examination, numerous infiltrative fungal organisms with septate and branching hyphae were noted and confirmed by periodic acid–Schiff stain with diastase (Figure 3). Also, multiple enlarged cells (likely dermal fibrocytes or macrophages) with large, purple intranuclear inclusions and surrounding clear halo, consistent with active CMV infection, were scattered throughout the biopsy specimens. Sputum cultures and tissue biopsy specimens yielded A fumigatus. Additional computed tomographic images of the thorax revealed nodular ground glass opacities in the remaining right lung. Voriconazole, lamisil, and ganciclovir therapy was initiated. The patient's clinical course continued to deteriorate. She ultimately received comfort measures and died 1 week after admission.
Tender Erythema of the Left Lower Extremity—Diagnosis. Arch Dermatol. 2007;143(4):535-540. doi:10.1001/archderm.143.4.536-b