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Clinical Challenge  Patient With a Rash, Abdominal Pain, and
Weight Loss  Figure 1. Florid erythematous maculopapular
blanching rash over anterior chest, with areas of confluence.
Figure 2. Coronal CT image demonstrating wedge-shaped splenic
infarction and minor thickening of large bowel in right iliac
fossa. Click on image to view a larger version.  Brent
O'Carrigan, BSc, MBBS(Hons), MMed(Clin Epi) A 49-year-old man
presents with right iliac fossa pain of 36 hours' duration. He
reports loss of appetite, weight loss, and increasing lethargy
over the preceding 10 months with intermittent constipation but
no other symptoms. He describes asymmetric altered sensation in
his distal lower limbs with left worse than right. The patient
smokes, has a history of illicit amphetamine and cannabinoid
use, and acquired tattoos in a correctional facility. Past
medical history is remarkable for an idiopathic splenic
infarction 6 months ago. On physical examination,