JAMA Clinical Challenge

A Violaceous Plaque in an Immunosuppressed Patient

Image of nonblanching and necrotic-appearing violaceous plaque on the patient's anterior neck

Robert Micheletti, MD
Misha Rosenbach, MD
A 56-year-old man with acute myelogenous leukemia develops a violaceous plaque on his anterior neck that expands rapidly over the course of one day. The patient was hospitalized a month earlier for salvage chemotherapy with clofarabine. His course has been complicated by prolonged neutropenia and fever of unknown origin, for which he is receiving meropenem, vancomycin, and voriconazole. Physical examination reveals a necrotic-appearing, nonblanching, violaceous plaque on his anterior neck with surrounding erythema (Figure). On close inspection, 2 similar violaceous papules are discovered on his tongue and scalp. The patient is febrile but otherwise asymptomatic, with recent negative blood cultures.

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Author Affiliations: Drs Micheletti (robert.micheletti@uphs.upenn.edu) and Rosenbach are affiliated with the Departments of Dermatology and Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania.