Sweet's syndrome associated with Staphylococcus aureus

On October 17, 2001, we examined a 47‐year‐old white woman with a 1‐week history of painful, burning, pruritic lesions on the arms (Fig. 1), legs, and back. Initial self‐treatment included Neosporin® and over‐the‐counter lotions with no response. Examination revealed several erythematous lesions, which appeared bullous, but felt solid on palpation and puncture. There was no mucosal involvement. A review of systems indicated generally good health with no fever, although the patient complained of fatigue and muscle aches. Her history included depression, hypertension, and anemia; her surgical history included cholecystectomy, excision of a soft tissue tumor, and spinal fusion. 1 The lesions on the patient's right arm were painful, pruritic, and erythematous, bullous in appearance, but solid on palpation She had also had two cesarean sections, the last of which coincided with her first episode of Sweet's syndrome in 1995. At that time, she developed diffuse, erythematous, urticarial papules on the right shoulder, both forearms, back, chest, both thighs, and left knee. Lesions also appeared in areas under bandages and after excoriations. A biopsy was performed, which confirmed Sweet's syndrome, and the patient was successfully treated with diphenhydramine hydrochloride (Benadryl®), diflorasone diacetate (Psorcon®), and a prednisone taper starting at 60 mg for the first week and ending with 20 mg on the third and last week. The patient suffered recurrences in April 1996 and again in October 1996, remaining well until October 2001. Her medications at the initial visit included bupropion (Wellbutrin®), fluoxetine (Prozac®), gabapentin (Neurontin®), and hydrochlorothiazide, all of which she had taken for at least 2 years with no reported intolerance. Bacterial culture and a punch biopsy from lesions on the left arm were obtained. Because the differential diagnoses included impetigo and ecthyma, the patient was treated with cetirizine (Zyrtec®), 10 mg at bedtime (q.h.s.), and cefdinir (Omnicef®), 300 mg twice daily (b.d.), prior to the arrival of the results of the culture and biopsy. On October 19, the patient complained of increasing pain and redness associated with the lesions on her right forearm and legs. She was prescribed halobetasol (Ultravate®) ointment b.d. At an office visit on the following day, new lesions were present on the thighs. The bacterial culture revealed no microbial growth at 3 days, and by now a biopsy had again confirmed the diagnosis of a