We report a case of neutropenic ulceration in a 42-year-old woman receiving
azathioprine for
pemphigus vulgaris. She developed multiple indolent
ulcers involving the nose, neck, and back, after about 6-8 weeks following commencement of
azathioprine 50 mg daily. The
ulcers were large, disfiguring, dry, and with basal necrotic slough. They were painless and did not discharge
pus. The absolute neutrophil count was severely depressed initially, but normalized following
azathioprine withdrawal. Swab culture revealed colonization with Klebsiella pneumoniae and the
ulcers healed with local
debridement, treatment with
imipenem, and topical application of
mupirocin. However, nasal disfigurement persisted. Neutropenic ulceration is known to be associated with
azathioprine therapy but we report this case because of the unusual presentation-indolent cutaneous
ulcers. Early recognition of the problem and
drug withdrawal can prevent complications like disfigurement.