A 48-year-old Japanese man presented to the emergency department with worsening dyspnea. He had a fouryear history of progressive skin lesions on his gluteal region which caused bleeding and pus discharge. The patient experienced dyspnea for 2 years during winter, which hindered his ability to ride bicycle for his job due to buttock pain. He reported wearing the same unwashed briefs for over a decade, during which he did not bathe regularly but showered occasionally to wash off pus and bloody exudate. Due to the large amount of exudate, a towel was placed inside his briefs, which was changed as needed. He had a 28-year history of smoking half a pack of cigarettes and alcohol consumption (1000 mL) q1d.

A 74-year-old woman was admitted with hypercalcemia and prolonged disturbance of consciousness. The left buttock to the anterior aspect of the left thigh was swollen and erythematous, with a collection of 1.0-cm large, firm, elastic nodules distributed in a zosteriform pattern in the L1-L4 region. Based on autopsy findings, a very rare case of Cobb syndrome was diagnosed due to a spinal vascular malformation at the Th12-L 4 level and L5 vertebral hemangioma. Cobb syndrome-associated cutaneous metastasis extending along the same metamere was complicated by immunohistochemically proven parathyroid hormone-related proteinproducing advanced bladder carcinoma in this case.