The patient WAS a 47 year old male, born in Brazi, who came to USA 3 years ago.
For more then a year he had recurrent epistaxis and recently developed ulcerating skin lesions. He was evaluated by an outside physician for pancytopenia and underwent a bone marrow biopsy which revealed numerous acid-fast bacilli without granulomas.

Clinical findings included:

• mild edema of the hands
• bilateral lower lateral leg ulcers that are shallow and had no evidence of infection
• large confluent and monomorphous erythematous plaques without central clearingoverlying the face, trunk, bilateral upper and lower extremities
• edematous and pendulous ears
• congested and edematous nose
• edematous hands and bilateral lower leg erosions
• no palpable nerves
• atrophic and sclerotic skin on the  distal extremities

 A biopsy from an ulcer on the ankle was reviewed.

clinical image

clinical image