1. TID Case Nicole Theodoropoulos, MD, MS The Ohio State University

2. Reason for Consult: tender shin nodules 34 y.o. woman with dilated cardiomyopathy s/p OHT 2009, CKD, h/o gastric bypass admitted to Ohio hospital in June for vomiting, inability to keep down oral medications and associated AKI ~2 weeks ago she developed subjective fevers, intermittent productive cough, fatigue, malaise, and constipation nausea with occasional emesis x 1 week Noticed new painful, non-pruritic, bumps on her legs for the week prior to admission Pertinent Meds: valacyclovir, mycophenolic acid, tacrolimus

3. Physical Exam/Labs Afebrile, normal vital signs Abd: ? Palpable spleen tip Skin: Small, 0.3-0.5, non-erythematous lesions on the shins, no associated erythema, extremely TTP \ 7.9 / 130 | 103 | 50 / 1.7 -------- 111 -------------------------- 102 / 25.3 \ 5.4 | 20 | 3.16\ ANC 1.2, ALC 0.2 LFTs normal except alk phos 375 CXR R basilar atelectasis

4. Initial Hospital Course MMF held due to pancytopenia Tacrolimus held due to acute renal failure Started on steroids for immune suppression ID and dermatology consulted about skin lesions Dermatology felt lesions were consistent with angiolipomas Lesions biopsied

5. What is the most likely cause of this patient’s presentation? A) Erythema nodosum B) Disseminated histoplasmosis C) Cryptococcal infection D) Tuberculosis E) Disseminated non-tuberculous mycobacterial infection

6. Skin Biopsy

7. What would you do next? A) Get a CT of the chest, abdomen and pelvis B) Send sputum for AFB smear and culture C) Start antibiotic therapy for M. marinum D) Send repeat skin biopsy for cultures E) Send Quantiferon-TB Gold test

8. Continued hospital course Chest CT: improved bibasilar atelectasis and 5 mm LUL nodule Abdomen/pelvis CT: lymphadenopathy and HSM, wedge shaped hypoattenuation in spleen Induced sputum x 3 with + AFB, MTB PCR negative Rpt skin biopsy w/o growth on AFB culture Blood AFB culture + Eventually identified as MAC Started ethambutol, rifabutin, azithromycin