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JAMA Clinical Challenge

Abdominal Pain and Subcutaneous Nodules

Image of erythematous nodules on foot and ankle of patient

Kurt A. Ashack, BA
Rebecca M. Jansen, MD
Henry W. Lim

A 63-year-old man is admitted for evaluation of recurrent abdominal pain and a 2-month history of tender nodules on the extremities (Figure). He has a history of hepatitis B, hepatocellular carcinoma, and idiopathic pancreatitis. The lesions are initially very painful and slow to resolve. New lesions tend to appear with, or immediately after, episodes of acute pancreatitis. Laboratory evaluation reveals elevated levels of serum lipase (2700 IU/L) and amylase (3400 IU/L). Previous treatments have included incision and drainage of a nodule on the right foot as well as oral and intravenous administration of antistaphylococcal antibiotics for presumed cellulitis. Examination of the skin reveals erythematous subcutaneous nodules symmetrically distributed on the bilateral lower and upper extremities, primarily on the lower legs and feet. One of the largest nodules has a small amount of yellow, oily discharge. The patient is afebrile and reports nausea, vomiting, and arthralgias.

See the full article for an explanation and discussion.

Author Affiliations: Drs Lim (hlim1@hfhs.org) and Jansen are affiliated with the Department of Dermatology, Henry Ford Hospital, Detroit, Michigan. Dr Ashack is affiliated with Michigan State University College of Human Medicine, East Lansing, Michigan.