N is a 50 year-old with myelodysplastic syndrome on azacytidine for 3 months who presents after numerous painful skin lesions developed over 2 weeks. One first appeared on their right arm and grew to 3 cm. Since then innumerable lesions have developed over torso and extremities beginning as raised nodules and growing to bullous lesions. Denies fevers, chills, changes in appetite or other symptoms. N lives in rural Appalachia and enjoys hiking on cultivated trails, but denies animal exposures. Basic chemistry and cell counts show no change from baseline, but neutrophil count has remained around 500 since diagnosis.