Case description
A 51-year-old man with a past medical history of 16 pack years of smoking presented to the emergency department with new onset severe bilateral ankle pain. He reported a 10-day history of fatigue, fever with a maximum temperature of 102.5 F, night sweats, and the development of erythematous, painful papular rashes that started on his knees and continued to spread all over the body. The patient also noted an episode of chest pain and dry coughs but denied shortness of breath and hemoptysis. Additionally, the patient reported a 24-lb weight loss over several weeks due to loss of appetite. He denied a history of oral or genital ulcers.
Occupational history revealed he worked on a city farm and had previously worked as an environmental specialist in a sewage plant. The patient denied a history of exposure to animal droppings, hazardous materials, recent travel outside the state, or sick contacts.
On physical examination, the patient was afebrile, and his respiratory system was unremarkable. Posterior cervical lymphadenopathies and multiple painful, well-circumscribed, erythematous, edematous plaques involving 10-12 % of his body surface area with sparing of the palms and soles were noted (Fig 1.1-1.3). Mild swelling and pain with motion of the bilateral ankles were observed.