A 79-year-old morbidly obese, afebrile, white woman with diabetes and end-stage chronic obstructive pulmonary disease, which was being treated with long-term oral prednisone therapy, was admitted to her local hospital for a presumptive diagnosis of cellulitis of the right arm. She also had a history of elephantiasis with recurrent cellulitis in her lower extremities. Two months earlier, she had been hospitalized for pneumonia. During the interim, family members noted that her right hand, a former intravenous site, continued to drain clear fluid and never healed. A vague history of headache was retrospectively given. Two days before admission, the site on her right hand was noted to have a blue discoloration. Hemorrhagic bullae and erythema of her forearm, with diffuse tenderness, subsequently developed (Figure 1). Therapy with timentin, vancomycin, and gentamicin was initiated for the presumptive diagnosis of cellulitis. Her initial laboratory tests were significant for the following values: white blood cell count, 15.1×109/L (differential cell count, 0.88 neutrophils, 0.10 leukocytes, 0.01 monocytes, and 0.01 eosinophils); erythrocyte sedimentation rate, 43 mm/h; and asymptomatic, nonfractionated creatine kinase, 253 U/L. There were no electrocardiographic changes. A chest radiograph showed interstitial pulmonary infiltrates. Dermatology was consulted on hospital day 5, and a biopsy specimen was obtained from her right arm (Figure 2).
Johnson DS, Hadley T, Mihm MC. Symmetrical Hemorrhagic Bullae in an Immunocompromised Host. Arch Dermatol. 1999;135(8):983–a–988. doi:10-1001/pubs.Arch Dermatol.-ISSN-0003-987x-135-8-dof0899
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