Be afraid of a long-standing skin lesion

A 91-year-old man presented to our emergency department for foul-smelling bleeding secretions and severe pain from a long-standing ulcerated skin lesion on his right frontotemporal area. This lesion had been present for over a year and originally measured about 2 cm. It had been managed at home with help from a nursing service but without any medical follow-up. Blood tests showed leukocytosis (WBC 16,800/mm³), increased C-reactive protein (174 mg/L, n.v.<5), and normochromic normocytic anemia (Hb 8.8 g/dL, MCV 94.7 fL, MCH 31 pg). The patient was admitted to the geriatrics department, and an empirical broad-spectrum antibiotic therapy with piperacillin/tazobactam (4.5 g q8h IV) and daptomycin (500 mg q48h IV due to severe CKD) was started. A CT scan of the brain revealed complete obliteration of the diploic-tecal structures across the entire frontal squama on both sides of the skull, with infiltration of the right temporal muscle. The expansive lesion extended into the intracranial site, only partially delimited by the dura mater, with coexisting right frontobasal perilesional edema extending up to the anterior convexity, which exerted significant compressive pressure on the frontal horn of the lateral ventricle with a left-right shift of the midline by approximately 3 mm. In the absence of surgical options and with persistent bleeding and severe pain, palliative sedation therapy was started. The patient died after 6 days of recovery.