History: 60-year-old male with acute myeloblastic leukemia was admitted to the hospital with E. coli line sepsis three weeks after completing a course of salvage chemotherapy. Dermatology was consulted for an isolated lesion on his posterior neck that was discovered three days prior to admission when his wife shaved his hair. The lesion is asymptomatic and both he and his wife had previously been unaware of it; he has not been bothered by it since its discovery. He reports no history of trauma to the site. Patient reports fatigue, and had experienced fevers and night sweats prior to beginning antibiotics for his known line sepsis, now resolved. He denies cough, chest pain, and dyspnea.
Past medical history: Acute myeloblastic leukemia diagnosed in 1990, status post matched related bone marrow transplant in 1991, relapse in 1997, and repeat matched related BMT in 2008, now with relapse and CNS disease. Completed a course of salvage chemotherapy three weeks ago. Neutropenia for the last three weeks. Hypertension, diabetes mellitus type 2 and peripheral vascular disease.
Medications:Ciprofloxacin, fluconazole, valacyclovir and trimethoprim/sulfamethoxazole for infection prophylaxis. Budesonide, prednisone and sirolimus for graft-versus-host disease. Amlodipine and metoprolol for hypertension. Insulin glargine for diabetes mellitus. Gabapentin for neuropathy.OxyContin as needed for pain.
Social history: Lives in rural Missouri on a horse farm. Employed in an office job for 40 years, gardens heavily as a hobby. No recent travel, but has in the past visited Western Europe, the Caribbean, Israel, and the southwest United States.
Physical exam: Temperature 36.6C, pulse 79, blood pressure 159/94, respiratory rate 16, oxygen saturation 94% on room air.Heart, lungs and abdomen were normal on exam. There was no palpable lymphadenopathy. On the neck, there is a sharply-demarcated annuular lesion measuring 2.5 x 2.5 x 0.5 cm with a necrotic center and erythematous, slightly elevated border (Figure 1).
Laboratory studies: WBC 0.2 k/mm3, hemoglobin 12.1 g/dl, hematocrit 35.4%, platelets 46 k//mm3
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