Immunosuppressed Returned Traveler With Ulcerating Skin Lesion and Fever

Clinical Infectious Diseases - current i.. - 3m ago Preview

 
 
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A 69-year-old immunosuppressed woman presented with a progressive ulcerating skin lesion (Figure 1) extending over her natal cleft, buttock, and perineum. The patient first noticed the lesion 1–2 weeks into her 4-month stay, where she was living with family in a residential area near Phnom Penh, Cambodia. She was a Cambodian national, and divided her time between Cambodia and Australia with her husband. After multiple courses of antibiotics, including flucloxacillin, penicillin, ciprofloxacin, and dapsone, no improvement was noted. The lesion was painful but nonpruritic, with preserved sensation to pinprick and temperature. No associated regional lymphadenopathy was appreciated. Full blood examination revealed a normocytic normochromic anemia (hemoglobin, 82 g/L), raised white blood cell count (11.2 × 109/L; reference range [RR], 4–11) with differential showing a neutrophilia 9.7 × 109/L and lymphopenia 0.6 × 109/L; baseline renal function (serum creatinine, 93 μmol/L; estimated glomerular filtration rate, 54 mL/minute/1.73 m2), and mixed deranged liver function tests (alanine aminotransferase, 87 U/L [RR, < 33]; aspartate aminotransferase, 57 U/L [RR, <32]; γ-glutamyl transferase, 59 U/L [RR, <40]; alkaline phosphatase, 150 U/L [RR, < 105]) with normal bilirubin and mild hypoalbuminemia (26 g/L).