June-July 2010




History: A 10 year-old mixed race female presented to her pediatrician with a 1 month history of fatigue, weight loss, and bone pain.  She was found to have a platelet count of 12 and a cbc of 900.  The patient was admitted and eventually diagnosed with B cell acute lymphoblastic leukemia.  She was treated with dexamethasone, cytarabine, and daunorubicin.  Her hospitalization was complicated by fevers to 39°C and verrucous papulo-nodular ulcerated plaques. She had pain of the left upper extremity that began after infiltration of her left arm and axilla with bicarbonate solution.


Past Medical History: negative prior to the episode leading to the hospitalization described above

Medications: IV Vancomycin, Amphotericin B, Zosyn

Physical Exam: verrucous nodulopapules and ulcerated plaques on the left upper extremity (Fig 1)


Serum Calcium: low to normal

Serum Phosphorus: low to normal


Blood Galactomannan- negative

Blood bacterial and fungal cultures- negative

Tissue AFB, fungal, and aerobic cultures- negative

MRSA nasal swab- positive, clindamycin sensitive

Blood CMV, VZV, EBV PCR- negative


MRI- diffuse subcutaneous edema of the left upper extremity extending to the outer fascia of the biceps and triceps muscle consistent with cellulitis, no fluid collection or abscess, normal underlying bone

Ultrasound- calcifications and cellulitis without a drainable fluid collection

Echocardiogram- no evidence of vegetations

Head CT- no mass lesion or hemorrhage

Chest/Abd/Pelvis CT- no explanation for the patient’s persistent fevers



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