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JAMA Dermatology Clinicopathological Challenge
October 2018

An Elderly Woman With Painful Buttock and Vulvar Ulcers

Author Affiliations
  • 1Division of Infectious Diseases, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
  • 2Department of Dermatology, American University of Beirut Medical Center, Beirut, Lebanon
JAMA Dermatol. 2018;154(10):1217-1218. doi:10.1001/jamadermatol.2018.0632

A woman in her 80s presented to hospital with somnolence and fatigue of 2 days’ duration. Medical history included lower urinary tract symptoms of 1-week duration for which she was prescribed cotrimoxazole with no improvement. She also reported progressively worsening vulvar and buttock pain of 5 days’ duration. The patient was admitted to the intensive care unit 3 weeks prior to presentation for pneumonia and remained hospitalized for 10 days. She was not sexually active and had no medical history of sexually transmitted infections. Anogenital examination revealed vulvar (Figure 1A) and buttock ulcers (Figure 1B) tender to palpation. Initial blood workup showed leukopenia with a white blood cell count of 2400 cells/μL (to convert to cells/L, multiply by 106), a differential of 72% neutrophils, and a hemoglobin level of 8.5 g/dL with a hematocrit differential of 27% (to convert hemoglobin to g/L, multiply by 10.0). Cotrimoxazole was discontinued on admission. A biopsy specimen was obtained from the left vulvar ulcer (Figure 1C).

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