JAMA Clinical Challenge Section Editor: Huan J. Chang, MD, Contributing Editor. We encourage authors to submit papers for consideration as a JAMA Clinical Challenge. Please contact Dr Chang at email@example.com
Author Affiliations: Department of Dermatology, First Affiliated Hospital, Zhejiang University, Hangzhou, Zhejiang, China.
A 57-year-old woman who received a renal transplant 10 years agois admitted for evaluation of edematous erythema, subcutaneous plaques, and severe lower extremity pain for 1 month. She has had a fever (39.2°C) for 10 days but denies headaches, nausea, and vomiting. Her lesions and fever have not responded to 3 separate courses of intravenous antibiotics (penicillin, ceftriaxone, imipenem). She denies any preceding injury or insect bite. Skin examination reveals diffuse tender edematous erythema and multiple ill-defined, indurated subcutaneous plaques on most of the lower extremities, without abscess or ulceration (Figure 1). Neurologic examination results are normal. Her medications include mycophenolate mofetil (1.75 g/d), cyclosporine (120 mg/d), and prednisone (15 mg/d). White blood cell count is normal, with 90% neutrophils; C-reactive protein level is elevated at 31.3 mg/L (298.1 nmol/L). IgG level is 677 mg/dL. Two repeat blood cultures are negative. Ultrasound and magnetic resonance imaging of lower extremities show no sign of abscess.
Ding Y, Fang H. Edematous Erythema, Subcutaneous Plaques, and Severe Pain in the Lower Extremities in an Immunocompromised Patient. JAMA. 2013;309(15):1632–1633. doi:10.1001/jama.2013.3740
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