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Painful Chronic Ulcers on the Neck and Back.

A man in his 60s who was a former smoker with a medical history of chronic obstructive pulmonary disease, type 2 diabetes, chronic kidney disease, anemia, and cervical myelopathy experienced low-grade fevers, unintentional 80-pound weight loss, productive cough, and development of cutaneous ulcers over a 6-month period after cervical spine fusion. Two ulcers developed at the surgical site, and 2 similar ulcers developed on his back shortly after cyst excision. He had been recently diagnosed with lung cancer based on computed tomographic (CT) and positron emission tomographic imaging showing an enhancing, hypermetabolic, 7-cm cavitary right upper lobe mass with mediastinal adenopathy. A chest x-ray 6 months prior revealed negative results. A few days after establishing care, he presented to the emergency department with extreme weakness and intolerable pain related to his ulcers. Physical examination revealed an ill-appearing man. In the right upper lobe, there were decreased breath sounds with clear auscultation in the remaining chest. On the right anterior neck were two, 3to 4-cm tender ulcers extending to the deep subcutaneous fat with erythematous, friable borders (Figure). On his back were 2 similar 2to 2.5-cm ulcers. Inflammatory markers were notably elevated. A complete autoimmune panel, indirect immunofluorescence assays, enzyme immunoassays for antineutrophil cytoplasmic antibodies (c-ANCA)/proteinase 3, antineutrophil cytoplasmic antibody/myeloperoxidase, a quantiferon gold test, cultures of blood, broncheoalveolar washings, and tissue analysis were performed. Only c-ANCA testing revealed positive results. A CT scan of the sinus showed multiple bony defects and acute and chronic sinusitis. A transbronchial biopsy of the lung and excisional biopsy of the skin bridge between back ulcers were performed. Histopathologic image C Histopathologic image D Histopathologic image B