A 25-year-old homosexual man with Bruton's X-linked agammaglobulinemia (XLA) was seen for a follow-up examination of chronic skin ulcers on his lower extremities that were thought to represent pyoderma gangrenosum (PG). The patient was feeling generally well, with no fevers or shortness of breath but with a mild chronic cough likely due to smoking. The patient's ulcers developed after minor trauma to his lower legs and had been treated with various antibiotics. For the prior 7 months, the lesions had shown great improvement, with complete healing after the addition of oral steroids, but they again flared with steroid tapering. Biopsy samples of the leg ulcers showed a mixed dermal inflammatory infiltrate with neutrophils and lymphocytes. Steiner staining of the biopsy sample showed numerous curvilinear rod-like organisms. A Gram stain (utilizing carbol fuchsin applied for 2 min as the counterstain) showed similar organisms. Multiple cultures were performed on the biopsy sample. Routine cultures from the leg biopsy sample grew a small amount of Pseudomonas aeruginosa after 2 days of incubation. After 7 days of incubation, a filmy haze of growth was noted in the primary quadrant of one of the other cultures. Organisms were visualized by Gram stain, again using carbol fuchsin as the counterstain, and are shown in Figure .
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