Raised Sedimentation Rate Research Articles

Mycobacterium chelonae hand infection following ferret bite

We present a case of hand infection caused by Mycobacterium chelonae. The patient was a 58-year-old woman with Type II diabetes mellitus and stage 4 chronic kidney disease. The infection occurred following a ferret bite and had not responded to oral antibiotics in the primary care setting. She developed signs of pyogenic flexor tenosynovitis of the index and middle fingers of her left hand. Laboratory parameters showed high C-reactive protein, raised erythrocyte sedimentation rate and leucocytosis. Ultrasound imaging confirmed the clinical diagnosis. Plain radiographs showed no osseous involvement. The infection was treated with surgical debridement and broad spectrum parenteral antibiotics. The intra-operative tissue specimens were initially negative on aerobic and anaerobic cultures. Following transient improvement of her inflammatory parameters and clinical signs, she developed a recurrence with added features of osteomyelitis of the index and middle finger metacarpal heads on repeat radiographs. A revision surgical debridement of the flexor tenosynovitis and osteomyelitis with specific long-term antibiotic cover has led to resolution of the infection. Extended cultures of the tissue specimens at the regional laboratory confirmed the causative organism to be M. chelonae. To our knowledge, this is the first reported case of M. chelonae infection resulting from a ferret bite. This case reminds us of the need for a high index of suspicion for infection with uncommon pathogens following animal bites, especially in patients with altered immune status.

What is your diagnosis?: Multiple asymptomatic nodules over the body with severe arthritis in a middle aged female

Thirty five year old female presented with severe joint pain involving knees, elbows, wrists, small joints of hands and lumbosacral spine for 3 years along with multiple skin colored, asymptomatic nodules scattered over her body for last 6 months. On examination, there were multiple discrete but grouped, firm, skin colored, non tender papules and nodules, ranging in size from 2 mm to 2 cm over multiple sites mainly involving trunk and bilateral upper limbs. Systemic examination was within normal limits. Routine blood investigations were normal except for raised Erythrocyte sedimentation rate (31 mm/h). Radiographs of bilateral hands showed erosive arthritis in left index, left middle, right index and right little finger. Punch biopsy from a nodule over dorsum of hand on histopathological examination showed circumscribed large focus of diffuse dense infiltrate of large histiocytes and histiocytic giant cells with the scattering of lymphocytes and few neutrophils. Thus the diagnosis of Multicentric Reticulohistiocytosis was confirmed. The patient was started on 30 mg prednisolone with 15 mg of methotrexate orally once a week. The patient noticed improvement in the joint symptoms but there was no improvement in cutaneous lesions.

The different faces of actinomycosis

A 48-year-old woman presented with a 4-week history of progressive, painful skin lesions on trunk and limbs. She reported fatigue, coughing, weight loss and diarrhoea. Her medical history included depression, tobacco smoking, and benzodiazepine and alcohol abuse. On physical examination, three indurated, erythematous, purulent plaques were seen on the lower back, right forearm and left scapula (180 · 60 mm, 70 · 40 mm and 20 · 20 mm in size, respectively). Firm, subcutaneous, purulent nodules were seen on the right hip and upper leg (Fig. 1a,b). The patient was apathetic, with a bloated abdomen, hepatomegaly, and inguinal and supraclavicular lymphadenopathy. The clinical differential diagnosis included lymphoma, inflammatory disease, paraneoplastic syndrome, panniculitis, cutaneous metastasis and lymphangitis carcinomatosa. A skin biopsy was taken. On histopathological examination, a deep chronic, purulent inflammatory infiltrate was seen, consisting of lymphocytes, plasmocytes, neutrophils and histiocytes. Focally Gram-positive radial filamentous organisms were seen, indicative of an infection. Laboratory investigations revealed raised erythrocyte sedimentation rate (56 mm ⁄ h; normal 0–19 mm ⁄ h) and increased levels of C-reactive protein (233 mg ⁄ L; < 10 mg ⁄ L), serum alkaline phosphatase (271 U ⁄ L; 40–140 U ⁄ L), and c-glutamyl transferase (50 U ⁄ L; 0– 40 U ⁄ L). Blood cell counts identified leucocytosis (21.7 · 10 ⁄ L; 3.5–10.0 · 10 ⁄ L), thrombocytosis (815 · 10 ⁄ L; 130–350 · 10 ⁄ L) and normocytic CP D

Investigation and Treatment of a Complicated Inflammatory Aortoiliac Aneurysm

Inflammatory abdominal aortic aneurysms (IAAAs) account for 5% to 10% of all abdominal aortic aneurysms, occurring primarily in males. Their true etiology is unknown. Symptoms and signs of IAAA are so variable that they present to a wide range of specialties. There is debate in the literature whether IAAA is a manifestation of systemic autoimmune disease. We describe the case of a young female patient with complicated inflammatory aortoiliac aneurysmal disease, illustrating diagnostic and treatment challenges that remain. Our patient had a positive autoantibody screen, raised erythrocyte sedimentation rate, positive enzyme-linked immunosorbent spot test, and saccular aneurysms, including infective and inflammatory etiologies in her differential diagnosis. Early diagnosis is crucial to limit disease progression, morbidity, and mortality. Medical management is important to address the underlying disease process, but a combination of endovascular and open surgical intervention is often necessary for definitive treatment. Available evidence offers plausibility for benefit of endovascular intervention over open repair.

Temporal Artery Biopsy is not Required in all Cases of Suspected Giant Cell Arteritis

Temporal artery biopsy (TAB) is performed during the diagnostic workup for giant cell arteritis (GCA), a vasculitis with the potential to cause irreversible blindness or stroke. However, treatment is often started on clinical grounds, and TAB result frequently does not influence patient management. The aim of this study was to assess the need for TAB in cases of suspected GCA. We performed a retrospective review of 185 TABs performed in our institution from 1990 to 2010. Patients were identified through the Hospital In-Patient Enquiry database and theater records. Clinical findings, erythrocyte sedimentation rate, steroid treatment preoperatively, American College of Rheumatology (ACR) criteria for GCA score, biopsy result, and follow-up were recorded. Fifty-eight (31.4%) biopsies were positive for GCA. Presence of jaw claudication (P = 0.001), abnormal fundoscopy (P = 0.001), and raised erythrocyte sedimentation rate (P = 0.001) were significantly associated with GCA. The strongest association with positive biopsy was seen with the prebiopsy ACR score (P < 0.001). Twenty-four (13.7%) patients had undergone biopsy, despite no potential for meeting ACR criteria preoperatively. None of these were positive. Overall, 29 (16.4%) patients had management altered by TAB result. Our results confirm that TAB does not affect management in the majority of patients with suspected GCA. We conclude that TAB has benefit only for patients who score 2 or 3 on the ACR criteria for GCA without biopsy.

Primary intravascular large B-cell lymphoma of pituitary

A 68-year-old retired nurse, who was a known hypertensive on medication, presented with prolonged fever of 2-month duration without any clinical evidence of infection. On examination she had altered mental status. She also had other nonspecific complaints such as sleep disturbances, loss of weight, etc. On investigation, she was found to have anemia, thrombocytopenia, raised erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and lactate dehydrogenase (LDH) values. She also had electrolyte imbalance. Radiological evaluation of brain showed mass lesion in the sella turcica, suggestive of pituitary adenoma. Biochemical evaluation showed hypopituitarism. Trans-sphenoidal biopsy was done. Based on histopathological and immunohistochemical findings a diagnosis of intravascular large B-cell lymphoma (IVLBCL) of pituitary was made. Our patient's condition deteriorated rapidly and she succumbed to her illness before therapy could be initiated. We are reporting this case because of the rare subtype of large B-cell lymphoma presenting at an extremely unusual primary site.

Postoperative disc space infection after discectomy: a report on thirty-five patients.

The focus of this study was to analyse the patient with disc space infection and the need for re-exploration. Thirty-five patients were analysed within the period from April 1992 and May 2011. The diagnosis was confirmed by the cardinal clinical features, raised erythrocyte sedimentation rate [ESR], raised C-reactive protein and MRI findings. All received 500-mg intravenous amikacin and one gram ceftriaxone at the time of anaesthetic induction and six hours after surgery. Age range was between 25-62 years. The appearance of symptoms was between four days and three weeks. Nine patients had silent chronic urinary tract infection. Twenty-nine patients had re-exploration while the others did well on conservative treatment. Neurological deficit was not recorded. All recovered well within six to nine months. Re-exploration is recommended if no response is achieved after four day's conservative treatment for or if the patient's condition is critical.

Haemopoietic Improvement Following Iron Chelation for Transfusional Haemosiderosis in Patients with Haematopoietic Neoplasia and Aplastic Anaemia: An Observational Study

Abstract 5050 Background:The benefit of iron chelation therapy (ICT) in patients with thalassaemia major is well established; however its role in adults with haematopoietic neoplasia (HN) and aplastic anemia (AA) is less certain. Post hoc analysis of the EPIC study revealed ICT therapy was associated with improved haemopoietic parameters in approximately 20% of patients with myelodysplasia (MDS). Deferasirox has been reported to inhibit NF-kB, a key transcription factor involved in the inflammatory response. We speculate that deferasirox may have an additional action as an immunosuppresive agent. Aim:To identify cases of HN and AA demonstrating haematopoietic improvement following ICT and the factors associated with response. Method:Multicentre observational study; Physician recall of HN and AA cases showing haemopoietic improvement with ICT. Results:Eight cases of haemopoietic improvement following ICT were identified: median age 60 (25–68), Male 5. Disorders included: hypoplastic MDS (3), aplastic anaemia (2) refractory anaemia with ringed sideroblasts (1) refractory cytopenia with multilineage dysplasia (1) and idiopathic myelofibrosis (1). All patients were transfusion dependent requiring 3.4 units/month (2.6–6.1) with a median pre-transfusion haemoglobin of 82g/l (66–95) prior to commencement of ICT, and baseline ferritin 1896 mcg/L (1017–5480). Two patients had raised erythrocyte sedimentation rate. All patients received deferasirox: median dose 12 mg/kg/day (5.6–20.6). Seven patients became transfusion independent but all had an erythroid response with median Hb following ICT of 120g/L (85–135). Median time to erythroid response: 96 days (61–450). Four patients received other therapies that may have contributed to their improvement. Six patients had platelet and four neutrophil responses. Conclusion:Haematological responses occurred prior to significant falls in ferritin and at deferasirox doses considered inadequate for ICT. The over-representation of patients with AA/hypoplastic MDS (5) and presence of raised inflammatory markers in two of three cases without marrow hypoplasia supports the hypothesis that deferasirox may have beneficial immunosuppressive activity and may explain the observed responses in this series. Prospective studies are needed.Novartis Australia provided support to facilitate discussions related to this topic. The company had no role in analysing the data or preparing the abstract, and its content is responsibility of the authors. Disclosures:Opat:Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees. Bird:Amgen: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; Novartis: Honoraria, Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; GSK: Membership on an entity's Board of Directors or advisory committees. Forsyth:Novartis: Membership on an entity's Board of Directors or advisory committees. Szer:Novartis: Membership on an entity's Board of Directors or advisory committees. Tam:Novartis: Membership on an entity's Board of Directors or advisory committees. Motum:Novartis: Membership on an entity's Board of Directors or advisory committees. Bentley:Novartis: Membership on an entity's Board of Directors or advisory committees.

Fluorine-18-fluorodeoxyglucose PET/CT rare finding of a unique multiorgan involvement of Wegener's granulomatosis

Wegener's granulomatosis (WG) is an uncommon autoimmune disorder, which mainly involves the blood vessels, kidneys and respiratory tract. We report an interesting case of WG with unusual multiorgan involvement in a young male who presented with a short history of right-sided otalgia, nasal obstruction and a right parotid mass. His initial CT and MRI scans showed a large parotid mass with features suggestive of malignancy with bilateral cavitating pulmonary nodules suggesting metastatic disease. The imaging-based differential diagnosis was squamous cell carcinoma or adenoid cystic carcinoma. The microscopic findings on ultrasound-guided biopsy of the parotid mass were, surprisingly, those of acute necrotising granulomatous inflammation with some features suggestive of a vasculitic process. A multidisciplinary team discussion and further investigation resulted in the additional findings of haematuria, raised erythrocyte sedimentation rate and positive serum cytoplasmic anti-neutrophil cytoplasmic antibody test, which led to the diagnosis of WG. Subsequently, the patient developed acute urinary retention owing to gross prostatic enlargement related to further disease involvement, which was confirmed with a positive biopsy. Fluorine-18-fluorodeoxyglucose (18F-FDG) positron emission tomography (PET)/CT scan showed disease distribution at the right maxillary sinus/nasal cavity, right parotid, mediastinum, lungs and prostate. To our knowledge, this is the first reported 18F-FDG PET/CT case with multiorgan involvement in a single WG patient. The patient has improved both clinically and on imaging after appropriate treatment with immunosuppressive therapy and steroids. Although 18F-FDG PET/CT imaging did not actually alter the management of this patient, it can help to establish the disease distribution and guide the biopsy.

Wegener's granulomatosis mimicking skull base osteomyelitis

To report a case of Wegener's granulomatosis mimicking skull base osteomyelitis. A case of Wegener's granulomatosis is reported in a diabetic woman presenting with facial palsy and hearing loss. The clinical course of the disease was very similar to that of skull base osteomyelitis, especially since the patient was diabetic and the ear swab was positive for pseudomonas. The definitive diagnosis was made based on clinical presentation, imaging and serum antineutrophil cytoplasmic antibody testing. The patient was started on immunosuppressants, and her hearing loss and facial palsy recovered. Wegener's granulomatosis is a systemic disease with various manifestations. A high index of clinical suspicion is required to reach the correct diagnosis. The clinician should be alerted to the possibility of Wegener's granulomatosis in the presence of: systemic upset out of proportion to the apparent intensity of the local lesion; middle-ear disease failing to respond to conventional treatment; and a consistently raised erythrocyte sedimentation rate.

Isolated intracranial Rosai-Dorfman disease mimicking meningioma in a child: a case report and review of the literature

We report the first case of extensive involvement of isolated intracranial Rosai-Dorfman's disease (RDD) in a child. Our case is unique because it presents with involvement of the middle cranial fossa, cavernous sinus, pituitary gland, orbit, ethmoid and sphenoid sinuses. Previous cases of intracranial RDD in children have reported separate involvement of cavernous sinus, suprasellar region, and frontal and petroclival regions. Involvement of the pituitary gland has so far not been reported. A 14-year-old male presented with a medical history of loss of vision, raised erythrocyte sedimentation rate (ESR), and abnormal prolactin and cortisol levels. Radiologically the diagnosis was meningioma. The histopathological diagnosis was RDD with emperipolesis and S-100 positivity. RDD is a histiocytic proliferation of unknown aetiology, which commonly affects lymph nodes. Uncommonly it involves the extranodal sites and rarely the central nervous system (CNS). 80 cases of RDD involving CNS have been reported in the literature, and only 5 were in children. Although the definitive diagnosis of RDD disease is based on the histopathology report, it should be included in the differentials of a lesion mimicking meningioma especially in children.

Polymyositis associated with hepatitis B: management with entacavir and prednisolone

We report a 57-year-old woman with a 20-year history of hepatitis B presenting with progressive proximal lower limb weakness for the previous 1 month. Previous medical history included a pericardial and pleural effusion, of which no cause was found and pulmonary tuberculosis which has been adequately treated. Examination revealed multiple telangiactasia over face and nail beds and bilateral proximal lower limb weakness of power 4/5. Biochemical investigation revealed a raised erythrocyte sedimentation rate of 36 mm/h, elevated creatinine kinase levels (14,363 IU/L) and raised liver enzymes (alanine aminotransferase 445 IU/L, aspartate aminotransferase 606 IU/L) with high hepatitis B virus DNA (1,021,158 copies/mL). Nerve conduction tests and muscle biopsy were consistent with polymyositis. She received entacavir for hepatitis B treatment. Despite treatment with entacavir for 10 weeks, her weakness persisted and prednisolone was added. Upon commencement of prednisolone, her symptoms and biochemical profiles returned to normal.

Lymphomatosis cerebri presenting as a rapidly progressive dementia with a high methylmalonic acid

We report a case of a patient with a rapidly progressive dementing illness and gait disturbance, in whom initial screening demonstrated a high methylmalonic acid level only, suggestive of a functional vitamin B(12) deficiency. Despite B(12) replacement therapy, he continued to decline. Further investigations demonstrated extensive signal change on magnetic resonance imaging involving grey and white matter within the corpus callosum, deep grey matter, brainstem and cerebellar peduncles, and patchy post-contrast enhancement. Laboratory testing revealed a raised erythrocyte sedimentation rate, raised anti-nuclear, intrinsic factor and lupus anticoagulant antibody titres, and a IgG kappa paraprotein. Cerebrospinal fluid was unremarkable. Bone marrow trephine biopsy showed monoclonal gammopathy of unknown significance. The patient initially responded to steroids, and underwent a brain biopsy, which was uninformative. However, 3 weeks following admission, he died due to an aspiration pneumonia. Autopsy findings were consistent with a diffuse primary central nervous system small cell B-cell lymphoma. This has been rarely reported in the medical literature, but our case exhibits typical clinical features, although patchy enhancement on imaging and the high methylmalonic acid have not been previously described. We hypothesise that his functional B(12) deficiency may have resulted from rapid cell turnover, perhaps in conjunction with the presence of intrinsic factor antibodies.

Risk and response adapted therapy for early stage Hodgkin lymphoma: a prospective multicenter study of the Australasian Leukaemia and Lymphoma Group/Trans-Tasman Radiation Oncology Group

In this prospective, multicenter, non-randomized study for patients with stage I–II Hodgkin lymphoma, group 1 (without risk-factors [RF]) had three cycles of ABVD chemotherapy (adriamycin, bleomycin, vinblastine, and dacarbazine) and group 2 (any of bulk, extranodal site, >3 regions, raised erythrocyte sedimentation rate [ESR]) and group 3 (B-symptoms) received four cycles. Involved field radiotherapy (IFRT) 30 Gy was given after adequate chemotherapy response. Five-year overall survival and freedom from progression (FFP) were 96% (95% confidence interval [CI] 91–98%) and 90% (84–94%), respectively. Five-year FFP was 97% (90–99%), 89% (75–95%), and 73% (52–86%) for groups 1, 2, and 3, respectively. In patients with RF, chemotherapy responses of complete response unconfirmed (CRu), partial response (PR), and stable disease (SD) were associated with FFP of 90%, 86%, and 62% (p=0.17), and CR/no CR on functional imaging with FFP of 90%/67%, respectively (p=0.05). The 97% FFP in group 1 compares favorably with previously reported results from cooperative trial groups. Intensification of therapy warrants study in patients with RF and a poor chemotherapy response.

Cardiovascular events in early RA are a result of inflammatory burden and traditional risk factors: a five year prospective study

IntroductionCo-morbidity and mortality due to cardiovascular disease (CVD) are increased in patients with rheumatoid arthritis (RA). Most published studies in this field are retrospective or cross sectional. We investigated the presence of traditional and disease related risk factors for CVD at the onset of RA and during the first five years following diagnosis. We also evaluated their potential for predicting a new cardiovascular event (CVE) during the five-year follow-up period and the modulatory effect of pharmacological treatment.MethodsAll patients from the four northern-most counties of Sweden with early RA are, since December 1995, consecutively recruited at diagnosis (T0) into a large survey on the progress of the disease. Information regarding cardiovascular co-morbidity and related predictors was collected from clinical records and supplemented with questionnaires. By April 2008, 700 patients had been included of whom 442 patients had reached the five-year follow-up (T5).ResultsAmong the 442 patients who reached T5 during the follow-up period, treatment for hypertension increased from 24.5 to 37.4% (P < 0.001)), diagnosis of diabetes mellitus (DM) from 7.1 to 9.5% (P < 0.01) whilst smoking decreased from 29.8 to 22.4% (P < 0.001) and the BMI from 26.3 to 25.8 (P < 0.05), respectively. By T5, 48 patients had suffered a new CVE of which 12 were fatal. A total of 23 patients died during the follow-up period. Age at disease onset, male sex, a previous CVE, DM, treatment for hypertension, triglyceride level, cumulative disease activity (area under the curve (AUC) disease activity score (DAS28)), extra-articular disease, corticosteroid use, shorter duration of treatment with disease modifying anti-rheumatic drugs (DMARDs) and use of COX-2 inhibitors increased the hazard rate for a new CVE. A raised erythrocyte sedimentation rate (ESR) at inclusion and AUC DAS28 at six months increased the hazard rate of CVE independently whilst DMARD treatment was protective in multiple Cox extended models adjusted for sex and CV risk factors. The risk of a CVE due to inflammation was potentiated by traditional CV risk factors.ConclusionsThe occurrence of new CV events in very early RA was explained by traditional CV risk factors and was potentiated by high disease activity. Treatment with DMARDs decreased the risk. The results may have implications for cardio-protective strategies in RA.

Rheumatisches Fieber

Rheumatic fever and rheumatic heart disease are caused by an auto-immune reaction that occurs following a Group A streptococcal infection. Prevalence of rheumatic fever and rheumatic heart disease has notably decreased in industrialised countries in the past 50 years. Both diseases mainly affect children and adolescents. The exact pathomechanism is not yet known. Following an infection with haemolytic Group A streptococcals typical signs and symptoms occur which can be divided into major and minor criteria after Jones. Major criteria include carditis, polyarthritis, Sydenham's chorea, erythema marginatum, and subcutaneous nodules. Minor criteria include fever, arthralgia, raised erythrocyte sedimentation rate and C reactive protein as well as leukocytosis. Rheumatic fever can be treated with anti-inflammatory medications such as salicylic acid. It is recommended to treat streptococcal infections with antibiotics within 9 days in order to prevent rheumatic fever and rheumatic heart disease.

Inflammatory Abdominal Aortic Aneurysm Successfully Treated With Steroid Therapy

![Figure][1] A 60-year-old man presented with a low back pain. Laboratory examination revealed a raised erythrocyte sedimentation rate of 83 mm/h, an elevated C-reactive protein of 3.9 mg/dl, and estimated glomerular filtration rate of 36 ml/min/m2. A computed tomography scan showed a 4.0-cm

Peritoneal mesothelioma

Peritoneal disease accounts for just under a third of all malignant mesothelioma. Its insidious onset means that diagnosis is often made at an advanced stage, however, new therapeutic techniques are starting to lead to improved outcomes.

Bone marrow signal during PET imaging in Hodgkin lymphoma

Positron emission tomography (PET) has added considerably to the management of Hodgkin lymphoma (HL). PET is of value in staging disease, response assessment and evaluation of a residual mass post-treatment. Full staging of advanced disease has traditionally required a bone marrow biopsy and this is still considered standard practise, although some authors argue that this rarely alters patient management. It had been hoped that the use of PET imaging at diagnosis would clearly define bone marrow involvement in HL and remove the need to perform bone marrow biopsies. It is clear, however, that PET cannot readily differentiate between ‘reactive’ and ‘involved’ bone marrow when the PET signal is diffusely increased in bone. The substrate, 2-fluoro-2-deoxyD-glucose (FDG), is readily taken up by metabolically active tissue and a reactive bone marrow with expansion of myeloid and lymphoid activity can show a degree of uptake very similar to that of bone marrow involved by disease. The first image (left) shows the FDG-PET signal from a patient with HL with a reactive bone marrow biopsy at diagnosis. The diagnosis of a reactive bone marrow was made from a single iliac crest bone marrow biopsy in association with a normocytic anaemia, neutrophilia and raised erythrocyte sedimentation rate. The second (centre) shows the FDG-PET signal from a patient with Stage 4 HL with heavy bone marrow infiltration shown by biopsy at diagnosis. The third (right) shows a normal bone marrow FDG-PET signal for comparison. PET is an invaluable imaging tool used in the assessment of patients with HL. However, it should be used to compliment bone marrow trephine biopsy, rather than replace it, if patients are to be accurately staged prior to therapy.

Sporotrichoid Mycobacterium marinum infection of the face following a cat scratch

Mycobacterium marinum infections in humans uncommonly affect the face and are not known to be associated with cat scratches. We describe a 24-year-old woman who presented with a 3-month history of multiple tender, occasionally discharging cystic nodules involving the left side of her face in a sporotrichoid distribution. She had suffered a cat scratch to her left lower eyelid 3 weeks before the onset of the eruption and owned multiple tropical fish tanks. She was systemically well and had no lymphadenopathy. She had a background history of a 4.5-mm-thick nodular melanoma of her temple treated by wide local excision and negative sentinel lymph node biopsy 4 years prior. Skin biopsies showed multiple variably sized granulomas surrounded by thick cuffs of lymphocytes involving the superficial and deep dermis with no organisms seen on Ziehl-Neelsen, peroidic acid-Schiff and methenamine silver stains. Laboratory investigations showed a mildly raised erythrocyte sedimentation rate but normal full blood count and C-reactive protein. Fluid from the left cheek grew an acid-fast bacillus identified as Mycobacterium marinum. The skin eruption cleared after 5-month treatment with oral clarithromycin 500 mg twice daily and rifampicin 600 mg daily.