21-Year-Old Male Trauma Patient With Skin and Liver Lesions, Hepatitis, and Coagulopathy

Abstract

A 21-year-old African-American male suffered multiple injuries from an improvised explosive device while deployed in Afghanistan. His trauma resulted in severe soft tissue injuries involving the posterior upper arms and left shoulder, as well as the left flank, which communicates with the abdominal cavity. A splenectomy was required due to the splenic lacerations that he received. During his hospital course, the complication of polymicrobial wound infection occurred, which required repeated debridements with wound vacuum (WV) placement and broad spectrum antibiotic coverage. Ten days after his injury, he developed coagulopathy with persistently bloody WV output that required multiple transfusions of packed red blood cells, platelets, and cryoprecipitate. The patient had no known prior medical problems, and there was no report of unusual exposures to pathogens during his 8 months of deployment. On examination, the patient was febrile, hypotensive, tachycardic, intubated, and sedated. Two weeks after his injury and during surgical intervention for wound debridement and wound hemostasis, his surgeon noted several yellow, soft, slightly raised, pustular lesions on the surface of his liver, 1 of which was biopsied. The patient also developed pustular skin lesions on his forehead, right axilla, and right thorax, 1 of which was also biopsied (Figure 1). His laboratory test results during this episode were as follows: white blood cell count 20.6 × 10(3)/μL with 23% bands; hemoglobin 11.5 g/dL; hematocrit 22.2%; platelet count 47 × 10 (3)/μL; prothrombin time 17 seconds; partial thromboplastin time 33 seconds; international normalized ratio 1.3; aspartate aminotransferase 873 U/L; alanine aminotransferase 470 U/L; total bilirubin 7.1 mg/dL, and direct bilirubin 6.9 mg/dL. His liver biopsy showed multifocal coagulative necrosis without zonation. His skin biopsy was diagnostic (Figure 2). What is your diagnosis?