A 61-year-old man with painless ecchymotic lesions in his right upper extremity was admitted to the hospital in Isparta, Turkey, in January 2015. He was consulted to dermatology clinic, and he was given amoxicillin treatment. Punch biopsy was taken from the lesions that have revealed PG. Steroid treatment was given at 40 mg prednisolone for 2 days. The lesions were regressed immediately. He also had symptom of fever. Abdominal tomography was performed, which revealed lesions as 32x22 mm in liver and 35 mm diameter in spleen that were considered as abscess. Necrotic cells were observed from percutaneous samples, which were taken from abscess. He was given antibiotics; however, the lesions appeared again. Because immature myeloid cells were seen in blood film, he was referred to our hospital in April 2015. In his anamnesis, it was found that he was diagnosed as MDS 6 years ago and had been treated with cyclosporine at 2x100 mg for 5 years, which was stopped in January 2015. On admission, his body temperature was 38.1 C. The laboratory tests showed: hemoglobin, 9.2 g/dL; white blood cells, 5.1x103/microL; and thrombocytes, 10x103/microL. Exogenous platelet apheresis replacement was performed. He had ecchymotic lesions in both his extremities (Figure 1). Magnetic resonance imaging was performed for lesions that favor tuberculosis infection. Aspiration from liver lesion revealed the presence of Mycobacterium tuberculosis, so antituberculosis treatment was started. Bone marrow investigation revealed MDS-refractory anemia with excess blasts (7%). For lesions in bilateral upper extremities, thalidomide treatment was started at 50 mg/d. Lesions began to regress, and the patient tolerated thalidomide well, so the dose was increased to 100 mg/d. After 1 month from the initiation of thalidomide treatment, the lesions in upper extremities had disappeared (Figure 2).
All of the ethical considerations were strictly handled in accordance with the Helsinki Declaration. As a standard of care/action of the hospitals of Hacettepe Medical School, it was confirmed based on patient records that the study participant gave written informed consent at the time of hospitalization and relevant diagnostic/therapeutic standards of care.