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July 2004

Multiple Skin Necrotic Lesions—Quiz Case

Author Affiliations
 

MICHAEL E.MINGMD

Arch Dermatol. 2004;140(7):877-882. doi:10.1001/archderm.140.7.877-a

A 50-year-old woman presented with black necrotic lesions over her left medial canthus and mastoid process. She had recently been diagnosed as havingHodgkin lymphoma and had received her first course of chemotherapy. Over the next 2 weeks, she became pancytopenic and developed sepsis. A subsequent bacterialculture of a venous access line tip yielded Staphylococcus aureus.

Despite antistaphylococcal treatment with intravenous benzylpenicillin and floxacillin, the patient's con dition deteriorated, and she was transferredto the intensive care unit at our hospital, where she received ventilatory and cardiovascular support and underwent hemofiltration. She was dependenton noradrenaline and adrenaline for inotropic support. Within 24 hours, she developed several large, black, necrotic ulcerations over the mastoid processand left medial canthus (Figure 1). Other necrotic lesions were also evident on the sole of her right foot (Figure 2). An echocardiogram was obtainedto look for an underlying thrombotic source. Although a possible thrombus was observed in her left ventricle, anticoagulation was con sidered to beinappropriate because disseminated intravascular coagulation had developed.

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