A 57-year-old woman who received a renal transplant 10 years agois admitted for evaluation of edematous erythema, subcutaneous plaques, and severe lower extremity pain for 1 month. She has had a fever (39.2°C) for 10 days but denies headaches, nausea, and vomiting. Her lesions and fever have not responded to 3 separate courses of intravenous antibiotics (penicillin, ceftriaxone, imipenem). She denies any preceding injury or insect bite. Skin examination reveals diffuse tender edematous erythema and multiple ill-defined, indurated subcutaneous plaques on most of the lower extremities, without abscess or ulceration (Figure 1). Neurologic examination results are normal. Her medications include mycophenolate mofetil (1.75 g/d), cyclosporine (120 mg/d), and prednisone (15 mg/d). White blood cell count is normal, with 90% neutrophils; C-reactive protein level is elevated at 31.3 mg/L (298.1 nmol/L). IgG level is 677 mg/dL. Two repeat blood cultures are negative. Ultrasound and magnetic resonance imaging of lower extremities show no sign of abscess.
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The Rational Clinical Examination
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