LAUSR

A 78-year-old man with chronic lymphocytic leukemia and neurogenic bladder with an indwelling suprapubic cystostomy presented with a small, painful lump surrounding his catheter site. The throbbing, lancinating pain started after a routine outpatient catheter exchange at his urologist’s office. He reported that the pustule spread in a centrifugal fashion, and degenerated into an ulcer. He was prescribed cephalexin for presumed cellulitis by his primary care doctor. In the ensuing 72 h, the lesion continued to expand and was accompanied with increased pain despite taking antibiotics. He reported subjective fevers and night sweats, and subsequently presented to an outside hospital, where he was hospitalized for 5 days to receive intravenous antibiotics for presumed failure of oral therapy. He received vancomycin and piperacillin-tazobactam empirically. His blood cultures were negative for bacteria and fungi, and because of a mild improvement in symptoms, he was discharged home with amoxicillin-clavulanic acid to complete a 10-day course. His wound did not improve. He re-presented 5 days after discharge with worsening, uncontrolled pain and a continuously sprawling ulcer. Vital signs upon presentation showed a temperature of 38.4 C, heart rate of 121 beats/min, blood pressure of 144/81 mmHg, and respiration rate of 18 breaths/min. Abdominal examination revealed normal bowel sounds throughout, no tenderness to palpation away from the ulcer site, non-tender splenomegaly, and no rebound tenderness or guarding. Skin examination on the lower abdomen demonstrated a 30 9 10 cm ulcer with gunmetal gray, undermined borders (Fig. 1). He had exquisite tenderness to light touch over the ulcer. Laboratory studies showed a complete blood count consistent with a known pancytopenia from chemotherapy received 4 months previously, noting that his white blood cell count of 3270/lL (ANC 2808/lL), hemoglobin 8.8 g/dL, and platelet count of 100,000/lL were relatively unchanged. A peripheral blood smear was consistent with chemotherapy-induced pancytopenia. Urinalysis, liver function, and coagulation studies were within normal range. Urine and serum antigen studies for Histoplasma capsulatum and Blastomyces dermatitidis were negative. Repeat blood cultures were negative for fungal elements and bacteria. Abdominal computed tomography scan showed superficial abdominal wall stranding, but no signs of abscess. A biopsy of the ulcer edge showed a diffuse dermal infiltrate composed of mature neutrophils. Gram stains and special stains for microorganisms (Periodic Acid Schiff, Gomori Methenamine Silver, and Acid-Fast Bacilli) were negative for any bacteria and subsequent tissue culture yielded no growth. The biopsy site also was exquisitely painful and started to spread. His painful lesion progressed despite treatment with vancomycin and meropenem for 5 days and his pain was inadequately controlled despite multiple analgesics. Given his failure to improve with broad spectrum antibiotics, the onset of his illness was revisited. He stressed that the wound worsened immediately after his & Michael Arthur Santos [email protected]