A 27-yo woman comes to your clinic for an intensely itchy swollen toe and malaise for several weeks. She states that she first noted her R great toe become red and swollen approximately 8 days ago. It has become progressively more “achey” with intermittent intense shooting pain, especially at night. She also says that a small boil has come up in the area more recently and that it has been continually “soaking her sock” with blood-tinged fluid. She denies fevers, joint pain, or other such lesions. She has numerous mosquito bites over her arms and legs. She has no significant past medical history. She drinks socially, does not smoke or use illicit drugs. Ten days ago, she returned from a 2-year stint in West Africa where she was a Peace Corps volunteer.  In Africa, she was healthy, though she recalls having 1-2 bouts of febrile diarrhea per year, each lasting approximately 1 week.  Her only medications are mefloquine for malaria prophylaxis and an OCT.

T 99.2  BP 116/74    HR 88     RR 12     O2 99% RA

PEX: Notable for two 7mm slightly raised, erythematous lesions on the distal medial surface of the R great toe, with 2 cm of surrounding erythema. There is tenderness to palpation and a copious serosanguinous drainage from one of the lesions (upper left in the picture below).  There is a small area  of superficial ulceration immediately surroundinge each lesion and no foul odor. There is no apparent nailbed or joint involvement. There is no streaking. There is mildly tender shoddy R inguinal lymphadenopathy. The rest of the physical exam is unremarkable, except for numerous 3-4mm slightly raised mildly pruritic papules on the exposed surfaces of the arms and legs, none of which are ulcerated or draining.