54 year old man with multiple sores

Presenter: Mike Garone DO, Natalie Steinhoff DO, Jessie Perkins DO

Dermatology Program: NSUCOM/Largo Medical Center

Program Director: Richard Miller, DO, FAOCD

Submitted on: May 27, 2016

CHIEF COMPLAINT: Multiple “sores” on the left hand, chest, and right neck

CLINICAL HISTORY: A 54-year-old man presents with multiple “sores” on his left hand, chest, and right neck. His clinical history reveals no signs of fevers, chills, night sweats, or unexplained weight loss. He denies experiencing nasal congestion, sore throat, epistaxis, mucosal erosions, nausea, vomiting, diarrhea, hematochezia, or melena. There is no reported history of immunodeficiency or HIV. However, he does report chest congestion and rhinorrhea occurring every morning, although he denies any prior history of allergic rhinitis.

The patient’s past medical history includes hypothyroidism, and he has a negative surgical history. His family history is notable for a father with prostate cancer. Socially, he works as a government-contracted pilot, making frequent trips to the Middle East. He consumes alcohol socially but denies tobacco use or illicit drug use. His current medication includes Levothyroxine, and he has no known drug allergies.

Three months prior to this presentation, the patient was in Iraq, where he experienced insect bites. He reports that some of these bug bites never healed. Initially, he was treated by his primary care physician with permethrin and triamcinolone 0.1% topical cream. Subsequently, he was treated with systemic azithromycin and pimecrolimus topical.

PHYSICAL EXAM:
Vital signs: Within normal limits
Constitutional: No acute distress, pleasant
Skin: erythematous nodules with central erosion and crust on the right neck, mid-chest, and left hand

LABORATORY TESTS:

CT of the chest, abdomen, pelvis showed degenerative joint disease and prostate enlargement but was otherwise negative.
CBC, CMP within normal limits.
Ultrasound of the left upper extremity showed lymphadenopathy.
Bacterial and fungal culture of the right neck came back negative.
Tissue culture of the left chest also came back negative.
PCR was done by the CBC and positive for the causative organism.

DERMATOHISTOPATHOLOGY:

Dermal infiltrate composed of lymphocytes with occasional plasma cells. On higher power, there are several parasitized macrophages. The organisms tend to organize at the periphery of the macrophages, the so-called marquee sign.