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JAMA Clinical Challenge |

Papules, Plaques, and Nodules in an Immunocompromised Patient

Xiao-Yong Man, MD, PhD; Min Zheng, MD, PhD
JAMA. 2012;307(4):404-405. doi:10.1001/jama.2012.18.
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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 1A), arms, and lower limbs, mainly around the knees (Figure 1B) 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.

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Figure 1. Initial presentation of patient's left wrist, A, and left knee, B.

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Figure 2. Histology of nodule. A, Biopsy specimen of dermal abscess (periodic acid–Schiff, ×20). B, Intracellular hyphae (arrowheads) in multinucleated cells in granuloma (periodic acid–Schiff, ×400). C, High magnification showing typical hyphae and spores within the cyst (periodic acid–Schiff, ×400).



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