December 2016







HPI: R.W. is a 64 yo African American female with a history of multiple myeloma s/p autologous stem cell transplant (10/2014) admitted to the oncology service for chemotherapy (daratumumab). In addition to her history of MM, she had been admitted numerous times at outside hospitals for a pseudomonas wound infection on her RLE. The site was debrided by plastic surgery and had undergone skin graft. Despite multiple admissions and treatments for RLE infections, she continued to spike fevers. She was admitted to BJC for assessment of her recurrent fevers as well as chemotherapy for her relapsing MM. Dermatology was consulted for numerous, new, firm erythematous papules surrounding the site of a previous Pseduomonas cellulitis on the right shin and calf, which resulted in significant lymphatic alterations and unilateral stasis dermatitis. The primary team was concerned about a fungal or mycobacterial infection in light of the immunosuppression from chemotherapy and her history of RLE infection.

 Physical Exam (Skin): Fig1a and Fig1b

Physical Exam: Right calf (Figs.1,2) with superficial ulcers x 2 and surrounding 2+ pitting edema and hyperpigmentation; surrounding 2-4mm firm red papules distributed on lower extremity surrounding ulcers with papules present more medially



Multiple Myeloma, Stage III (dx 4/11/14); IgG Kappa paraprotein

Chronic Kidney Disease, Stage III-IV 2/2 to MM


Diabetes Mellitus Type 2

C. difficile colitis


Paroxysmal Atrial Fibrillation

RLE wound s/p skin graft


Social Hx:

Marital status: Single

Tobacco Use: never a smoker

ETOH: no history

Recreational drugs: no history


Family Hx:

Reviewed, non-contributory



Lisinopril- cough



Acyclovir 125mg q24 hrs

Amlodipine 5mg daily

Dartumumab 1385mg once

Famotidine 20mg daily

Linezolid IVPB 600mg q12 hrs

Meropenem IVPB 500mg q24 hrs

Metoprolol 25mg BID

Montelukast 10mg qpm

Sevelamer for RENVELA 1600mg TID with meals

Vancomycin 125mg q6 hours


Laboratory results:


Na+: 138, K: 4.1; Cl: 104,CO2: 19 (low); Glucose: 101; BUN: 40(high); Cr: 6.46 (high); Ca: 8.7; Plasma protein: 8.1; Albumin: 2.1 (low); Bilirubin: 0.4; AlkPhos: 113; AST: 42; ALT:10



WBC: 7.4; RBCs: 2.32 (low); Hbg: 6.7(low); Hct: 20.3(low); MCV: 87.5; Plt: 17 (low-critical)

PT: 19.4 (high)

INR: 1.79 (high)

PTT: 37.4 (high)


LDH: 689 (high)


Protein electrophoresis:

Albumin fraction: 2.2 (low); alpha-1 fraction: 0.7 (high); alpha-2 fraction: 1.0 (high); beta-1 fraction: 0.2 (low); gamma fraction: 2.9 (high); gamma restricted peak fraction: 2.7 (high)

IgM: <25 (low); IgG: 3614 (high); IgA: <50 (low); Kappa/Lambda cell ratio: 284.13 (high); Kappa free light chain: 179.0 (high); Lambda free light chain: 0.6 (wnl)


Click here for the Diagnosis.