A 62-YEAR-OLD WOMAN sought care at our clinic for painful skin lesions that had developed on her thighs 5 days earlier. She had received ongoing treatment at our clinic over the past few years for diabetes, hyperlipidemia, hypertension, and sarcoidosis. In the last 2 years, she’d had 2 hospitalizations for acute renal failure, with a creatinine value as high as 3.8 mg/dL and a persistent glomerular filtration rate consistent with stage 3 chronic kidney disease.
The medications she was taking included glyburide, pravastatin, and lisinopril. During the 2 years prior to her recent clinic visit, she’d had some intermittently elevated calcium readings. Repeat calcium levels each time were normal. In addition, her parathyroid hormone levels fluctuated between low, high, and normal. Her technetium sestamibi scan was negative for hyperparathyroidism. The patient was unemployed and gave no history of recent travel, injuries, or exposure to animals.
On examination, we noted large, poorly demarcated, warm, indurated erythematous lesions on her lateral thighs. She was given a diagnosis of cellulitis and treated with trimethoprim/sulfa-methoxazole 160/800 mg twice daily for 10 days. During follow-up visits 3 and 7 days later, she indicated that the lesions were less painful and they appeared to be less swollen.
Three weeks later, the patient returned to the clinic with skin sloughing that had produced necrotic lesions with black es-char on the bases (FIGURE 1). In addition, new lesions appeared on her anterior thighs. An initial punch biopsy of the lesions revealed no significant pathologic abnormality.
FIGURE 1
What started as indurated plaques…
The patient initially came in for the treatment of indurated plaques, which developed into ulcerative skin lesions with erythematous edges and eschar on the bases.
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