Diffuse skin nodules in an oyster farmer: Disseminated Mycobacterium marinum

A 66-year-old Caucasian male with ankylosing spondylitis on infliximab, methotrexate, and prednisone presented with a diffuse nodular skin rash over 6 months. It started as painless red papules over the pretibial area and then progressed to diffuse erythematous nodules with central necrosis. He had pain and swelling in bilateral wrists with high grade fevers, chills, and night sweats. The patient was an avid gardener and worked as an oyster farmer in the Chesapeake Bay.