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Course: Scattered Painful Papulonodules in an Older Woman

CME Credits: 1.00

Released: 2023-07-20

A 56-year-old woman with a history of multiple myeloma complicated by therapy-related acute myeloid leukemia was admitted for myeloablative conditioning in preparation for allogeneic hematopoietic cell transplant. Her course was complicated by severe mucositis, acute kidney injury, and neutropenic fever. During her admission, the patient also developed painful necrotic skin lesions, a nonproductive cough, and altered mental status.
Physical examination findings demonstrated dusky, purpuric, and pink papulonodules, some with overlying eschar, scattered on the scalp, neck, trunk, and extremities (, A). Laboratory study results revealed a white blood cell count of 150/?L (reference range, 3500/?L to 10,500/?L), an absolute neutrophil count of 130/?L (reference range, 1500/?L to 7400/?L), and a platelet count of 19?×103/?L (reference range, 150?×103/?L to 400?×103/?L). (To convert the white blood cell and neutrophil counts to cells ×109/L, multiply by 0.001; conversion of the platelet count to cells ×109/L is 1:1.) Blood culture results were negative. The results of a computed tomography (CT) scan of the brain showed no acute intracranial hemorrhage, territorial infarction, or mass effect. The results of a CT scan of the chest demonstrated multifocal bilateral ground-glass patchy opacities, scattered solid bilateral pulmonary nodules, and a moderately sized pericardial effusion. A biopsy specimen from a skin nodule on the left lateral thigh was obtained for histopathologic examination and tissue culture, and wet mount preparation of a tissue culture colony was performed (, B).


Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.


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