A 48-Year-Old Man With Bilateral Hand Edema and Ulcers

A 48-year-old man with diabetes mellitus presented to the emergency department with bilateral hand erythema, edema, and a large, purulent ulceration with eschar of the left hand (Figure 1). He also had hyperpigmented, indurated plaques and subcutaneous nodules of the bilateral lower extremities and left knee swelling. Lesions appeared 2 weeks prior to presentation, a few days after the patient was seen by Rheumatology and started on methotrexate, etanercept, and prednisone for joint swelling of the hands and suspected rheumatoid arthritis. Oral antibiotics were prescribed by his primary care physician; however, no improvement was noted after 2 weeks, prompting referral to the emergency department. His history was notable for a motorcycle accident 10 years prior to presentation. He worked as a pipe fitter, denied contact with animals, and underwent a left total knee arthroplasty 6 years after the motorcycle accident, which he reported was complicated by a joint...