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Case of the Month - July 2013

Dr John Black, Division of Infectious Diseases and HIV Medicine, UCT

A 38 year old man from the Eastern Cape presented to a Cape Town hospital with acute diarrhoea. He had been diagnosed with HIV in 2009 (CD4 count of 1 cell/mm3) and was initiated on first line ART. He subsequently failed first line therapy and was switched to Tenofovir, Lamivudine and Aluvia in 2012 when his CD4 count was 55 cells/mm3.

He was markedly wasted (38kg), with diffuse impetigo and multiple subcutaneous abscesses. MRSA was cultured from pus draining from one abscess, as well as a non-typhi Salmonella from stool.

His abscesses was drained and treated with Vancomycin for 4 days followed by topical Mupirocin. His skin cleared rapidly and his diarrhoea settled without treatment.

He subsequently developed an unexplained neutropenia, with a WCC 1.7 x 109/L (absolute neutrophil count 0.13 x 109/L). Three days later, he developed new skin lesions (see figures) and a high spiking fever. Blood cultures were taken and he was started back on Vancomycin to cover what was thought to be a recurrence of the staphylococcal skin lesions.

A Gram-negative bacillus was subsequently cultured from blood cultures sets and a pus swab from one of the new skin lesions.

Question 1: What is the likely clinical diagnosis of the skin lesions?

Continue to Answer 1