A 55-year-old white woman presents with a 9-month history of nonhealing ulceration inferior to the right axilla. The patient does not recall any trauma or antecedent event but remembers cleaning a garage in northern California 3 days prior to ulcer appearance. The wound was initially small but subsequently enlarged and developed satellite ulcers. Multiple courses of both topical and oral antibiotics and topical steroids did not improve the condition. The patient reports that nonadherent granulation occurs and that the ulcer often produces clear drainage, bleeds easily, and is extremely painful. She denies that the affected site was ever blue, gray, or black in color. After months of evaluation by numerous physicians, the patient is diagnosed with a brown recluse spider bite.
Physical examination is notable for a 5 cm x 4 cm well-demarcated circular ulcer of the right lateral chest, inferior to the axilla (Figure 1). The left lateral border shows overgranulation. The right lateral aspect reveals increased depth with fibrinous exudate. Three adjacent superficial ulcers, each approximately 1 cm in diameter, are also present. The surrounding skin is notable for macular erythema. There is no cervical or axillary lymphadenopathy. The remainder of the patient’s full skin examination is within normal limits. Scars are noted on bilateral breasts from prior mastectomy and reconstruction surgery.
Has the patient been correctly diagnosed?