A 49-year-old woman with metastatic colon and primary infiltrating ductal breast carcinoma presented with a 10-day history of multiple facial ulcerations after having received two courses of chemotherapy with cisplatin and fluorouracil and 30 Gy of total brain irradiation. These lesions initially appeared 3 days following her second course of chemotherapy as erythematous plaques that developed bullae and subsequently opened and drained. When the patient presented to her physician 1 week prior to admission, she was afebrile and had mucositis, the facial lesions mentioned above, and a white blood cell count of 0.9 X 109/L. She was treated with nystatin for her mucositis and cefadroxil for her facial ulcerations. She also continued to receive dexamethasone for cerebral edema secondary to brain metastases. Over the next week, her facial lesions continued to enlarge, and she developed a new bulla on her abdomen.On admission to the hospital, the patient was afebrile and had stable vital signs. Examination of her skin revealed five deeply ulcerating tumors on her right cheek, right and left chin, right forehead, and right medial canthus. They had erythematous rolled borders and a black central eschar (Fig 1). She also had a 3-cm nodule with white central necrotic tissue and bullae on her left lower abdomen (Fig 2).Laboratory studies included a complete blood cell count, which revealed a white blood cell count of 26X10VL, with a differential cell count of 0.42 segmented neutrophils, 0.21 lymphocytes, 0.19 band cell forms, 0.07 metamyelocytes, 0.06 myelocytes, and 0.04 promyelocytes. A skin biopsy specimen was taken from one of these ulcérations (Fig 3).
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