HPI: 72 year old Caucasian male presented with a non-healing lesion on left arm that appeared shortly after a dirty forklift crush injury about 3 months prior. Initially it appeared like a “pimple” that had been progressively enlarging. He had no  other lesions on his arm and was in otherwise good health. He had been treated by his PCP with multiple topical and systemic antibacterials and antifungals including ciprofloxacin, moxifloxacin, topical bactroban, topical ketoconazole and diflucan without any improvement.


PMH: GERD, HTN, hypothyroidism, bladder cancer s/p excision, nephrolithiasis, HLD, SCC of the skin, OSA on CPAP


Social Hx: Never smoker, 1-3 drinks weekly, denied any illicit drug use. Owned a plant nursery where he worked daily.


Family Hx: noncontributory


Allergies: Keflex, Penicillins, Sulfa drugs, Tetracyclines


Medications: Omeprazole, Levothyroxine, Meloxicam, Atenolol, Tamsulosin


Physical exam:

On the dorsal aspect of the left forearm, there was a 3cm wide erythematous granulomatous plaque without ulceration (Fig.1).



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