Abstract
A 40-year-old Japanese male presented to the emergency room with fever and acute hypoxemic respiratory failure. Diffuse, non-blanchable, erythematous, and coalesced papules were noted distributing over the face and four extremities (Fig 1). Chest radiograph showed bilateral diffuse alveolar infi ltrates (Fig 2). Hemogram displayed marked leukocytosis with a total white blood cell count of 41,600 /uL. Hypercalcemia with serum calcium level of up to 4.1 mmol/L was found. Serum intact parathyroid hormone level was within normal limits. Non-contrast computed tomography (CT) of the thorax showed extensive bright enhancement over the bilateral lung fi elds, myocardium, and bilateral serratus anterior muscle just beneath scapulae, and hepatosplenomegaly, while Tc99m methylene-diphosphate bone scintigraphy demonstrated abnormal tracer uptake of the bilateral lung fi elds, stomach, and four extremities (Fig 3).
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