Q. A 28-year-old male presents to the emergency department with a primary complaint of “fever and chills”. He reports a two-week history of recurrent night sweats, headache, fatigue, and muscle pain (myalgia). He has no known sick contacts. The patient is an intravenous (IV) drug user and sleeps by the river underneath an overpass. He takes no prescription medications regularly, and does not receive any form of preventative healthcare. On physical examination, his temperature is 39 degrees Celsius (102.2 degree Fahrenheit), blood pressure 128/80, heart rate 72/min, respiratory rate 18/min, and oxygen saturation is 98 percent on room air. His lung and cardiac examination are unremarkable. The patient has multiple, pinpoint lesions and scarring in various stages of healing in his antecubital fossa bilaterally. Additionally, irregular, nontender hemorrhagic macules are detected on his palms and thenar eminences bilaterally (see photo). Based on what you know at this point, what is the most likely etiology of the skin findings on this patient’s hands?