Tender Ulceronecrotic Nodules in a Patient With Leukemia —Quiz Case

Abstract

A 64-year-old woman with chronic lymphocytic leukemia presented with a 2-week history of burning and painful nodules on her legs, abdomen, and arms. Her eruption started 4 days after she began taking the clinical trial drug navitoclax, a targeted smallmolecule antagonist of the antiapoptotic lymphocytic protein Bcl-2. Otherwise, she felt well and denied recent travel. Physical examination revealed numerous tender, erythematous to ulceronecrotic, 1to 3-cm nodules onher arms, abdomen, and thighs (Figure 1). The early lesions were slightly erythematous indurated plaques. The later lesions were necrotic and purulent nodules. Six biopsy specimens were obtained from the necrotic lesions, 3 for histologic examination and 3 for culture. Histologic examination showed suppurative inflammation with tissue necrosis, with no organisms identified on special stains. All tissue cultures were negative for organisms. Based on this information, a 3-week regimen of empirical coverage for atypical mycobacteria with doxycycline hydrochloride, ciprofloxacin, and clarithromycin was initiated. The therapy was discontinued when the patient showed no improvement. Subsequently, oral prednisone therapy (60 mg/d) for a presumed neutrophilic dermatosis was initiated; however, it was discontinued 3 days later because of clinical deterioration. Another biopsy was performed on a new early lesion on the right side of the patient’s back (Figure 2 and Figure 3). What is your diagnosis?