History: JM is a 44 white male with no significant past medical history presented to an outside hospital with one day of hemoptysis with rapid decompensation. He was intubated and transferred to Barnes hospital with respiratory failure, right lower lobe infiltrate, septic and cardiogenic shock. He was treated with broad spectrum antibiotics and vasopressor support. Many tests were performed; however, the underlying diagnosis proved elusive. On day seven of hospitalization, he developed a rash in the bilateral axillae. Skin biopsy was performed of a lesion leading to the diagnosis.
SHx: Welder for Union Pacific RR, drinks 3-4 beers per day and smokes 1 pack per day for many years.
Medications: No medications at home. In the hospital: azithromycin, vancomycin, meropenem, epoprostenol, esomeprazole, folate, dobutamine, norepinephrine, thiamine, methylprednisolone
Physical exam: Red patch with surrounding rim of petechiae in the left axilla (Figure 1) and a necrotic ulcer with a red-violet border in the right axilla (Figure 2)
Initial CBC: WBC 2.8k, Hgb 10.0, Platelet 72k
Initial ABG: 7.4 6/28/61
Initial CMP: Creatinine 1.9, Protein 6.3, Albumin 2.9
Heme labs: LDH 383, Retic 3.4%, Bili 0.3, Haptoglobin 66.9, fibrinogen 617, peripheral flow cytometry negative for AML and MDS panel, Bone marrow biopsy hypercellular with myeloid predominance/left shift.
ANA negative, DSDNA negative, ANCA negative, anti-GBM negative, Scl-70 negative, ENA negative
Micro:HIV negative, routine blood cultures negative, fungal isolator negative, BAL negative, thoracentesis negative (all studies), AFB negative, Cryptococcus negative, Urine histo negative, tracheal candida positive, respiratory viral pathogen multiplex PCR negative.
Imaging: Initial chest CT demonstrates right lower lobe consolidation (figure 3)
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