A 30-year-old man who is an intravenous drug addict (not known to be Hiv-positive) was admitted to hospital complaining of fever and general malaise. The last dose of heroin had been administered 4 days previously and he had been taking dextropropoxyphenone since then. On admission, the leukocyte count was 9,200 per mL (neutrophils 8,100, lymphocytes 250), hemoglobin 12.4 g per dL, and the platelet count was 183,000 per mL. After a radiologic diagnosis of pneumonia was made, cloxacillin (1 g every 8 h iv) and gentamicin (80 mg every 8 h iv) were started, together with fluconazole (100 mg per day orally) for oropharyngeal candidiasis. Methadone, lorazepam, and flunitrazepam were given to prevent an opiate withdrawal syndrome. Seven days after admission, 12 erythematous maculae, of 5 mm diameter, were seen on the anterior thorax, together with pancytopenia (leukocyte count 700 per mL, neutrophils 600 per mL, lymphocytes 0 per mL, hemoglobin 10.9 g per dL, platelets 16,000 per mL) and persistent fever. Two days later, the patient died of acute respiratory insufficiency. Pneumocystis carinii and acid/alcohol-resistant bacilli were later confirmed by stain and culture, in the sputum, as was the positive HIV serology. A skin biopsy specimen showed a neutrophilic inflammatory infiltrate, together with necrosis of the epithelial cells of the eccrine coils (Fig. 1). The epidermis and the eccrine ducts in the dermis were intact. Neither mucin deposits nor squamous metaplasia of the eccrine ductal epithelium were seen. Special staining for bacteria, fungi, and acid-fast bacilli was negative.
