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A 70-year-old man with obesity, hypertension and congestive heart failure presented with a fever of 4-days' duration and pain in both his anterior shins. He had progressive chronic lymphedema of the lower extremities for the last 5 years. The lymphedema had started as recurrent swelling involving the dorsum of his feet, with ultimate involvement of both the front and the back of the legs; his genitals were not involved. He had not travelled outside of Italy in the 10 years before the lymphedema developed.
Physical examination revealed chronic bilateral skin changes involving the lower two-thirds of his legs. His skin was generally tender and brown, with generalized lichenification and verrucous, cobblestone-like papules and nodules that gave his legs a "woody" feel (Figure 1A, Figure 1B). Slight fissures were also present between some of the nodules.
Cultures from selected open skin areas grew Candida albicans, Staphylococcus epidermidis and â-hemolytic streptococcus group A. A biopsy specimen from a representative nodular lesion showed hyperkeratosis, parakeratosis and acanthosis of the epidermis, as well as edema and dilated lymphatic spaces in the papillary and reticular...