A woman with longstanding diabetes comes to your clinic to establish care. On exam, you note the following skin lesions, which she notes has been present for several months. The lesions are non-painful and non-pruritic but are noted to have ulceration at sites of trauma.
This week’s image challenge is inspired by a recent case presented at Morning Report by Dr. Mehwish Ismaily.
A 68-year old white man is brought in by his daughter for a month of progressive fatigue, fever, headache, and chills. Over the past week, he has become progressively encephalopathic as characterized by disorientation to time and place. He has no past medical history and is not on any medications. He is gainfully employed, lives in Texas, is monogamous with his wife, does not use illicit drugs. He hunts deer. On exam, he is febrile, oriented only to self, is without rash, and has no focal weakness, cranial nerve deficits, or hyperreflexia. Laboratory data is notable for thrombocytopenia, mild leukopenia with left shift, mild transaminase elevation, and mild lactate dehydrogenase elevations. Serum chemistries are otherwise normal. His serum haptoglobin and bilirubin are normal. Thyroid studies are normal. Lumbar puncture was performed after platelet transfusion. This demonstrated lymphocytic pleocytosis and mild CSF protein elevation. The patient was empirically covered with central nervous system dosing of vancomycin, cefepime, ampicillin, and acyclovir with minimal improvement in symptoms over the next two days. Manual evaluation of peripheral blood smear was obtained and the following abnormality was identified. These were described as punctate, deep-blue spherules arranged in a group within a granulocyte. No schistocytes were seen.