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February 21, 2011

Large Eschar on the Dorsal Surface of the Hand—Quiz Case

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Arch Dermatol. 2011;147(2):235-240. doi:10.1001/archdermatol.2010.423-a

An 84-year-old man presented with a 1-month history of a progressively enlarging necrotic eschar on the dorsal surface of his left hand. He reported sustaining a superficial injury while fishing. The eschar did not respond to clindamycin and levofloxacin. His medical history was remarkable for non-Hodgkin lymphoma as well as interstitial pulmonary pneumonitis that was treated with prednisone and azathioprine. He was also taking trimethoprim-sulfamethoxazole for Pneumocystis jiroveci prophylaxis because of his concomitant immunosuppression and pulmonary infiltrates. Physical examination revealed a 3.5-cm black, necrotic eschar withsurrounding induration on the dorsal surface of the left hand overlying the first web space (Figure 1). No axillary or epitrochlear lymphadenopathy was appreciated. An incisional biopsy specimen was obtained for histological analysis (Figure 2 and Figure 3). A complete blood cell count failed to reveal leukocytosis.

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