Infectious Diseases Case of the Month
Rash and Skin Biopsy

A 47 yo hispanic male was seen in infectious diseases clinic for a rash.

The patient was born in Puerto Vallarta, Mexico where he had resided the entirety of his life until moving to Warden, Washington (Central Washington) approximately seven months prior to his clinic visit.

He had first developed a rash on his right cheek five months prior to his clinic presentation. Subsequently, he developed focal areas of rash above his left eyebrow and on his extremities. There may have been numbness or discomfort associated with areas of the rash. At the time of his examination there was a raised erythematous plaque encompassing most of his right cheek, a 2-3 cm plaque over his left eyebrow, a 3-4 somewhat annular lesion of his proximal right thigh (similar to that pictured at left). Several smaller areas of rash were elsewhere on his extremities. The rash had not responded to prior courses of oral antibiotics nor topical corticosteroids.

The patient had worked with dairy cattle as his occupation both in Mexico and currently in Warden. He often would drink the fresh unpasteurized milk. Some of the cattle at Warden had recently died but he did not think their rate of death was excessive. He was unaware of tuberculosis amongst the cattle either in Mexico or in Washington.

The patient was married though his wife and children remained in Mexico. He had not previously had significant medical illnesses, had received no blood transfusions, and denied risky sexual behaviors. He felt well, was afebrile, and denied chills, sweats, weight loss, cough, or other indications of systemic illness.

Laboratory evaluation included WBC 5.4, Hgb 14.8, Plts 204. ANA was negative.

The patient underwent a skin biopsy. Routine H & E stains showed areas of vaguely granulomatous inflammation. Ziehl-Neelsen stains were negative. A photomicrograph of the Fite stain is pictured at left. Cultures were subsequently negative.

What organism is the most likely cause of his illness?
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Which micro-organism was the likely cause of this patient's illness?

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