Recurrent Multifocal Cellulitis

A 67-year-old Man With Recurrent Multifocal Cellulitis: A 67-year-old Caucasian man, an avid traveler with a history of hypertension, depression, and previous morbid obesity treated with bariatric surgery, presented with low-grade fever and recurrent left-ankle painful rash (Figure 1A). The patient noted the first episode 2 months prior to presentation when he presented with a poorly defined painful erythematous patch over his left ankle and leukocytosis. He was treated with cefazolin for suspected cellulitis and discharged on cephalexin with partial improvement. Infectious workup, including blood cultures, echocardiogram, and x-ray, was negative. Over the next few weeks he developed similar discrete episodes with new, noncontiguous rashes to other body parts, such as the abdomen, left shoulder (Figure 1B), right gluteal region, right elbow, and left knee that spontaneously resolved within a few days, sometimes without antibiotic treatment. A partial response to antihistamines, leg elevation, and doxycycline was noted, but rash and pain worsened with a short trial of steroids after initial improvement. Two days prior to admission, he again developed left-ankle painful erythematous rash spreading up to his knee, associated with fever. He had an extensive travel history with trips to China, India, South Asia, Canada, and Brazil in the last decade. Five months previously he had visited Hong Kong where he had a diarrheal illness consisting of 4–5 loose but not watery stools for 2 days that self-resolved. Three months previously he visited Morocco where he rode a camel. He lives in Missouri and has retired but volunteers with refugees hailing from the developing world receiving treatment for tuberculosis. He is a former sushi chef and eats raw seafood often. On presentation, he was febrile to 38.3°C but otherwise had stable vital signs. Laboratory data revealed leukocytosis (12 300 cells/μL) and elevated erythrocyte sedimentation rate (49 mm/h) and C-reactive protein (103 mg/L). Blood cultures were collected, and the patient was started on vancomycin and cefepime. Rheumatologic testing was negative, as was testing for syphilis, human immunodeficiency virus, tuberculosis, and Lyme disease. Left lower extremity computed tomography showed superficial soft tissue edema without osteomyelitis or abscess. Echocardiogram showed normal ventricular function without vegetations. Skin biopsy revealed sparse perivascular and interstitial inflammatory infiltrate consistent with cellulitis with negative tissue bacterial cultures. The aerobic bottle from 2 sets of blood cultures obtained on the day of admission yielded a pathogen whose microscopic features are shown in Figures 2 and 3.