60-year-old male, smoker of 20 cigarettes/day, COPD (chronic bronchitis type). Herniated discs L4-L5-S1-S2 operated, biliary lithiasis with cholestasis pattern. Gastric adenocarcinoma (T3N1M0, IIIa) operated 4 years earlier by total gastrectomy + splenectomy + distal pancreatectomy + oesophago-jejunal and jejuno-jejunal Roux-en-Y anastomosis, without subsequent chemotherapy or radiotherapy. Epigastralgia and frequent diarrhoea together with megaloblastic anaemia secondary to malabsorption. For 4 months she had been treated with phenytoin for epileptic seizures. Follow-up by the Oncology Department with no evidence of tumour recurrence, although she was being treated chronically with dexamethasone.
She was admitted due to increased diarrhoea and a fever of 38ºC, with skin lesions on the lower limbs described as pustular and blistering, and signs of pneumonic consolidation in the D base confirmed by X-ray. The fever and pneumonic condensation disappeared after treatment with levofloxacin for two weeks. The abdominal pain, diarrhoea and heart rhythm disturbances also disappeared after treatment with digitalis, but the weakness of the lower limbs and skin lesions persisted, extending over the legs, arms, hands and back, predominantly erythematous, some with vesicles on the surface which, when ruptured, left a necrotic centre.
Neither the imaging techniques performed (CT scan of the skull, thorax and abdomen and bone scintigraphy) nor the bone marrow aspirate and biopsy showed metastatic lesions or tumour infiltration. MRI of the spine revealed osteomalacia; decreased levels of 25-OH-D were observed. This osteomalacia could be explained by intestinal malabsorption of vitamin D, pancreatic insufficiency or treatment with anticonvulsants, three circumstances that occurred simultaneously in this patient. Blood culture, urine culture and stool culture were negative, as were HIV and CMV serology.
For the diagnosis of the dermatological lesions, samples were taken for pathology and microbiology. The biopsy reported cells with foreign body inclusions suggestive of malignant disease or dermatophytosis. Microbiological examination confirmed dermatophytosis, with isolation of Trichophyton mentagrophytes in the culture of the sample taken from the hand lesions, and Alternaria sp in the culture of the sample taken from a lesion on the leg. Treatment with oral itraconazole was started with a very good clinical response, and the patient was discharged from hospital a few days later, although he was under review by the Dermatology and Internal Medicine Departments.