Chief Complaint: “I have red bumps on my skin that keep getting bigger and sometimes bleed.”

History of Present Illness:
A 39-year-old man presents with multiple red, vascular-appearing skin lesions that have been growing over the past four weeks. The lesions started as small red papules but gradually increased in size, forming nodular, friable masses that occasionally bleed. He also reports low-grade fever, fatigue, and mild night sweats.

The patient has a history of HIV, but he has not been taking antiretroviral therapy (ART) regularly. He denies recent trauma, insect bites, or exposure to sick contacts.

Past Medical History:

• HIV (last CD4 count unknown)
• No prior opportunistic infections
• No known drug allergies

Physical Examination:

• Skin: Multiple red to purple vascular nodules on the face, upper trunk, and arms; some lesions have ulceration and bleeding
• Lymph nodes: Mild cervical and axillary lymphadenopathy
• Oral exam: No oral Kaposi sarcoma lesions
• Systemic exam: No hepatosplenomegaly

Diagnosis:
The patient’s presentation of friable, vascular skin lesions in the setting of untreated HIV raises strong suspicion for bacillary angiomatosis, caused by Bartonella henselae or Bartonella quintana.

Diagnostic Tests:

• Skin biopsy with Warthin-Starry stain: Shows bacillary clusters within the vascular lesions
• Blood culture (for Bartonella spp.)
• HIV viral load and CD4 count

Management Plan:

• First-line treatment: Oral doxycycline or erythromycin for at least 3 months
• Start or optimize ART for HIV
• Follow-up: Monitor for resolution of skin lesions and improvement of systemic symptoms

The patient is counseled on the importance of adherence to ART and preventive measures against Bartonella infection, including avoiding contact with cats and controlling body lice.