A 73/M, from Thanjavur, Tamil Nadu, had a history of erythematous patchy rash with papulonodular lesions for the last 3 years for which he had received multiple short courses of oral prednisolone over 3 years with pulse methylprednisolone therapy given at another center the previous year. Lesions resolved mildly with therapy only to recur later. He was a known diabetic (poorly controlled with OHA + Insulin) for 10 years.
He now presented with worsening of skin lesions with ulcerations and nodular eruptions over extremities associated with fever and chills since one week. On examination, he had reduced superficial sensations over both hands and feet with more impairment over left L3-L5 dermatomal distribution. Other systemic examination was unremarkable.
Investigations showed haemoglobin of 8.3g/dl, platelets-9,83,000/μl ,TLC-29,000/μl (N- 72 L-23 M- 5). Peripheral smear - neutrophilic leukocytosis with toxic granulations with thrombocytosis and giant platelets. HbA1c:7.2 , ESR- 140 , CRP- 143. HIV ELISA –negative. Blood cultures after 96 hours showed no growth. There was no response to IV meropenem and clindamycin. ANA/ANCA/anti MPO Ab and other vasculitis workup was negative.
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