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October 2002

Pustular Eruption

Author Affiliations

Copyright 2002 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2002

Arch Dermatol. 2002;138(10):1371-1376. doi:10.1001/archderm.138.10.1371

A previously healthy 58-year-old black man presented with a 4-day history of productive cough, pleuritic chest pain, myalgias, weight loss, and fever. Hematology studies revealed a white blood cell count of 21.7 × 103/µL) (reference range, 4-10 × 103/µL), and chest x-ray films revealed a left lower lobe infiltrate. The patient was diagnosed as having community-acquired pneumonia, hospitalized, and started on a regimen of azithromycin (Azithromax), without improvement. Ceftriaxone sodium (Rocephin) was subsequently added to the regimen; however, the patient continued to have an elevated white blood cell count and temperature spikes to 38.9°C. Other antibiotics were tried, without response. Blood and urine cultures were negative for organisms, and serologic tests were negative for human immunodeficiency virus, serum cryptococcal antigen, and toxoplasma IgM. A sputum sample was negative for Pneumocystis carinii and acidfast bacilli, but showed mixed oropharyngeal flora and few budding yeasts, with cultures pending. On the ninth day of hospitalization, a widespread 2- to 3-mm pustular eruption developed on the patient's face, arms, and chest (Figure 1). A pustule was drained and treated with 10% potassium hydroxide (Figure 2), and tissue obtained at biopsy was stained with methenamine silver (Figure 3) and sent for histologic examination and culture.

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