Author Affiliation: Central Clinical School, University of Sydney, Camperdown, Australia.
A 49-year-old man presents with right iliac fossa pain of 36 hours' duration. He reports loss of appetite, weight loss, and increasing lethargy over the preceding 10 months with intermittent constipation but no other symptoms. He describes asymmetric altered sensation in his distal lower limbs with left worse than right. The patient smokes, has a history of illicit amphetamine and cannabinoid use, and acquired tattoos in a correctional facility. Past medical history is remarkable for an idiopathic splenic infarction 6 months ago. On physical examination, he is cachectic and he has right iliac fossa tenderness and percussion tenderness. He has a demarcated, erythematous maculopapular rash across his torso and limbs (Figure 1). Neurological examination reveals an asymmetric lower limb sensory neuropathy.
O’Carrigan B, Cheong JY. Patient With a Rash, Abdominal Pain, and Weight Loss. JAMA. 2012;307(8):843–844. doi:10.1001/jama.2012.198
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