September 2005




History: A 54-year-old female with a 12-year history of CLL, who was three days status post chemotherapy presented with new-onset fever (103oF), pancytopenia, and a 3-month history of crusted violaceous nodular plaques on the right forearm. Her total leukocyte count was 0.9 x 103/µL (3.7-10.5 x 103/µL) and her absolute neutrophil count was 781. Despite negative blood and urine cultures as well as broad antibiotic coverage with vancomycin and voriconazole, her fevers persisted. Her lesions were painful, pruritic and slowly increasing in size over the three months prior to admission. Sinus, chest, and abdominal CT were negative for infection.

Physical Exam: There were three crusted, exophytic, violaceous plaques localized to her right forearm corresponding to the skin sites which were occluded by her IV tape placed three months prior to admission. The two larger plaques which flanked the prior IV site measured 2 x 2.5 cm and 3 x 2.5 cm (Figures 1 and 2).


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