October 2000



History: A 77-year old male with history of rheumatoid arthritis and myasthenia gravis on azathioprine and prednisone was admitted to the intensive care unit in respiratory distress. Tracheal specimens revealed pneumocystis carinii and abundant yeast, and the patient was begun on trimethoprim sulfamethoxazole and intravenous amphotericin B. During his first two weeks of hospitalization, purpuric lesions developed over his left arm and a dermatology consultation was requested.

Physical Exam: Exam revealed an ill-appearing intubated elderly white male with diffuse non-erythematous edema of his left arm. Isolated ecchymoses and hemorrhagic bullae were present around the antecubital fossa and on the lateral left arm (Fig. 1). Tissue biopsies were sent for pathology and fungal culture to rule out Aspergillosus.

Laboratory Exam: WBC 7.2 (93% PMN), Hematocrit 25.3, Platelets 23 ,Absolute lymphocyte count 0.3 (low). Dopplers of left upper extremity were negative for DVT.

CXR revealed bilateral lower lobe infiltrates. Blood cultures were negative. CSF showed mild elevation of protein

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