A 55-year-old man presented with a chronic cheek ulcer. The lesion, a reddened nodule measuring 0.5 cm, had developed 2 months earlier. He was treated with cephalexin, followed by moxicillin/clavulanate and then with moxifloxacin, but the lesion has not resolved.
It ulcerated slowly, without pain, and the patient was eventually referred to the infectious diseases service. History Medical history: Hypertension Medications: Hydrochlorothiazide Allergies: None Habits: None Pets: Dog Diet: Regular Travel: Has traveled throughout the Pacific Northwest of the United States Immunizations: Up to date Sports/water exposure: Hunting Infectious disease exposure: None Physical examination Vital signs: Temperature, 99.4° F; pulse, 80 beats/min; respiratory rate, 16 breaths/min; blood pressure, 130/80 mm Hg General: Non-ill-appearing HEENT: Nickel-sized ulcer on cheek, slightly raised edges,…
