Skin Lesions and Neutropenic Fever in a 69-Year-Old Woman

Cameron Nichols, MD; Fnu Nutan, MD


June 26, 2020

Physical Examination and Workup

Upon physical examination, the patient was noticeably short of breath. The site around her port was not erythematous, warm, or tender, and no drainage was observed. A 4-5 cm erythematous, edematous plaque was present on her back. It was warm and tender with some overlying crust (Figure 1).

Figure 1.

A similar plaque was seen on her right posterior calf, and her chest had erythematous and tender papules. She had a low-grade fever (100.4°F [38°C]) and tachypnea (25/min). She was pancytopenic, with a white blood cell count of 1.5 x 109/L and an absolute neutrophil count of 0.3 x 109/L. Her platelet count was 10 x 109/L. Upon admission, her hemoglobin level was 6 g/dL, and she required 2 U packed red blood cells. Chest radiograph findings were unremarkable.

A punch biopsy was performed on the plaque on her right calf, and the specimens were sent for histopathologic examination. A portion was sent for tissue cultures. Hematoxylin and eosin stain findings revealed mild spongiosis and acanthosis, as well as papillary dermal edema. The dermis also contained patchy perivascular inflammation, which was variably lymphoplasmacytic and neutrophilic. Abundant extravasated red blood cells were noted. Special stain results were negative for infectious agents.

The tissue was cultured for bacteria, fungus, acid-fast bacteria, and nocardia. No growth was observed on any of the culture plates after 1 month.


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