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Case of the Month - January 2015

Dr Evan Shoul

(With special thanks to Dr Peter Swart, Consultant Anatomical Pathologist, NHLS Division of Histopathology, Charlotte Maxeke Johannesburg Academic Hospital)

A 55-year-old man was referred from the Dermatology clinic with a diffuse rash. Towards the end of 2013, he noticed subcutaneous lumps over his left upper arm and back, which gradually ruptured through the skin to form scaly ulcers. Some of the lesions were occasionally associated with a purulent discharge. Over the next few months, more lesions developed, now involving his face and legs. Of note, a lesion appeared on his nose, starting as a pimple., which gradually extended into the nasal cavity, eroding through cartilage. It was associated with a thick, purulent and, at times, bloody nasal discharge.

He had attended his local clinic a number of times but had showed no response to courses of oral antibiotics. He had no other significant symptoms. He reported no constitutional symptoms and a systemic enquiry was unremarkable.

He was diagnosed HIV positive in March 2013 at another hospital after presenting with oropharyngeal candidiasis. His CD4 count then was 54 cells/mm3, but he failed to return to the clinic to commence anti-retroviral therapy. He had been otherwise well up until the current presentation and reported no previous episodes of tuberculosis or prior hospital admissions. He was currently on no chronic medication.

He lives alone in Cape Town but travels widely throughout the country for his work. He reports no international travel. His animal exposure includes goats, chickens and stray dogs around his house in a peri-urban settlement. His business requires extensive travel throughout the Western and Northern Cape, including on-site training in forested areas. His colleagues are all well and his family history is unremarkable.

On examination, he was afebrile with mobile, non-tender, soft, generalized lymphadenopathy. His oral cavity was normal but had discrete lesions on the face, trunk and limbs as shown in the following images:

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