A 58-year-old man was seen at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, on August 17, 2001, with two nonhealing, punched-out ulcers near the right lateral malleolus. The ulcers were approximately 2 cm x 2.5 cm in size, with necrotic margins, purulent exudate, and a foul odor. On the second day, temperature of 39.4 C and gangrene of the right leg developed. The patient also had alcoholic liver disease and non-Hodgkin lymphoma, for which he had been receiving chemotherapy for last 6 months, and he had had a 6 months' course of antitubercular combination therapy for pulmonary tuberculosis 2 years earlier.
Peripheral blood showed a leukocyte count of 10,000/mm3 with 80% neutrophils, 11% lymphocytes, and 9% monocytes. The fasting blood glucose level was 400 mg/dL with normal electrolytes and renal function test results. Liver function tests showed a serum glutamic oxalacetic transaminase level of 80 IU/L and a serum glutamic pyruvic transaminase level of 75 IU/L. Sputum microscopy showed no acid-fast bacilli. Microscopy of necrotic tissue showed gram-positive bacilli (1-1.5 mum x 5-6 mum) with frequent oval terminal spores. Aerobic blood culture was sterile. Insulin was given to control his blood glucose level. Antimicrobial therapy included intravenous metronidazole, vancomycin, and imipenem. Skin and subcutaneous tissue debridement and fasciotomy were also undertaken.