The skin biopsy specimen demonstrated necrotic foci within the dermis, neutrophils, leukocytoclastic debris, and an area surrounded by a granulomatous inflammatory infiltrate. High magnification demonstrated an infiltrate of histiocytes and giant cells adjacent to an area of necrosis. Special stains (methenamine silver, tissue gram stain, and acid-fast bacilli) were negative for organisms. Tissue cultures and aspirates from a fluctuant lymph node were negative for bacteria and fungi. Titers for plague, Coccidioides, and tularemia were measured, and a Francisella tularensis titer of 1:320 was obtained (negative, <1:80).