May 2012






History: 69 y/o male with a history of Multiple Myeloma and Rheumatoid Arthritis on Prednisone 7.5mg daily presents to the emergency department with fever and ulcers on his hands and feet.  He was discharged the previous day from an extended hospital admission for suspected bacterial meningitis.  His family informed the admitting physicians that his right foot had been progressively swelling for ~3 months, and that there had been an ulcer over the posterior R heel, for which an MRI was performed to rule out osteomyelitis.  The patient was not complaining of any pain.  His right foot continued to swell over the course of his hospital stay, and the margins of the ulcers extended.


Physical Exam:  Elderly male in no acute distress, but appears ill.  He has several erythematous ill-defined patches ranging in size from 2-5cm scattered over his trunk and distal extremities.  Several ulcers with rolled edges and surrounding erythematous smooth plaques and violaceous patches are present on the extensor toes and plantar foot draining serosanguinous fluid along with reticulated erythematous patches (Fig. 1).  On the R anterior leg are 2 sharply bordered, longitudinally arranged ulcers are present with surrounding erythematous plaque and violaceous patches (Fig. 2).

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