A previously healthy 58-year-old black man presented with a 4-day history of productive cough, pleuritic chest pain, myalgias, weight loss, and fever. Hematology studies revealed a white blood cell count of 21.7 × 103/µL) (reference range, 4-10 × 103/µL), and chest x-ray films revealed a left lower lobe infiltrate. The patient was diagnosed as having community-acquired pneumonia, hospitalized, and started on a regimen of azithromycin (Azithromax), without improvement. Ceftriaxone sodium (Rocephin) was subsequently added to the regimen; however, the patient continued to have an elevated white blood cell count and temperature spikes to 38.9°C. Other antibiotics were tried, without response. Blood and urine cultures were negative for organisms, and serologic tests were negative for human immunodeficiency virus, serum cryptococcal antigen, and toxoplasma IgM. A sputum sample was negative for Pneumocystis carinii and acidfast bacilli, but showed mixed oropharyngeal flora and few budding yeasts, with cultures pending. On the ninth day of hospitalization, a widespread 2- to 3-mm pustular eruption developed on the patient's face, arms, and chest (Figure 1). A pustule was drained and treated with 10% potassium hydroxide (Figure 2), and tissue obtained at biopsy was stained with methenamine silver (Figure 3) and sent for histologic examination and culture.
Friedman R, Henson T, Skinner R. Pustular Eruption. Arch Dermatol. 2002;138(10):1371-1376. doi:10.1001/archderm.138.10.1371