JAMA Clinical Challenge

Papules, Plaques, and Nodules in an Immunocompromised Patient

Initial presentation of patient's left wrist, A, and left knee, B.

Xiao-Yong Man, MD, PhD
Min Zheng, MD, PhD
An 85-year-old man is admitted for evaluation of multiple papules, plaques, and subcutaneous nodules on his face, trunk, and extremities. The patient has itching. There is no history of trauma. He has an 8-year history of diabetes and Sjögren syndrome with eye and mouth involvement and has been treated with varied doses of oral methylprednisolone for 5 years. During the 3 years prior to admission, he took 12 mg/d of methylprednisolone. Over the last 5 months, he received topical steroids and antifungal agents. Skin examination reveals multiple erythematous papules on his face and eyelids, clustered or solitary reddish or purple papules, indurated shining plaques, and subcutaneous nodules on his wrists (Figure, A), arms, and lower limbs, mainly around the knees (Figure, B) and thighs. Pus is not expressed with pressure. There are no lesions on his scalp, eyebrow, upper lip, chin, axillae, pubic area, palms, or soles.

See the full article for an explanation and discussion.

Author Affiliations: Dr Zheng (minz{at}zju.edu.cn) and Dr Man are affiliated with the Department of Dermatology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China.