| Abstrakt: |
A 25-year-old woman presented in October 1999 with fever, nausea, vomiting, and a nodular eruption that had developed over the previous 7 days. Her past medical history was significant for chronic sclerosing cholangitis, which necessitated a liver transplantation in 1994 and a second one in 1998 due to graft rejection. Upon admission, she was taking the following medications: prednisone 20 mg q.d., cyclosporine 375 mg p.o. b.i.d., sirolimus 10 mg p.o. q.d., levofloxacin 500 mg p.o. q.d., and ganciclovir 1000 mg p.o. t.i.d. On skin examination, there were tender, nonfluctuant, erythematous, subcutaneous nodules, 0.3–1.0 cm in diameter, scattered on her arms and legs (see Fig. 1). While undergoing diagnostic evaluation, the patient was empirically treated with intravenous antimicrobials for presumed sepsis as well as increased dosages of glucocorticosteroids for the possibility of acute graft rejection. Her laboratory data were significant for elevated liver function tests, blood urea nitrogen, and creatinine. A punch biopsy of a nodule on her left forearm showed a neutrophilic and histiocytic lobular and septal panniculitis (see Fig. 2), and all special stains, including acid-fast bacillus (AFB) stains, and tissue cultures were negative for infectious organisms. Although the patient's eruption was compatible with erythema nodosum both clinically and histologically, it failed to improve during the next few weeks with an increased dosage of glucocorticosteroids. A second skin biopsy was then performed on a lower extremity nodule and it revealed a necrotizing panniculitis with numerous AFB. Within 7 days, skin tissue culture grew Mycobacterium chelonae/abscessus complex sensitive to amikacin and clarithromycin, but resistant to cefoxitin, doxycycline, ciprofloxacin, sulfamethoxasole/trimethoprim, and erythromycin. Re-examination of the initial biopsy revealed a very small focus of AFB which was not previously recognized. Due to persistently elevated liver... [ABSTRACT FROM AUTHOR] |
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