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JAMA Clinical Challenge

Generalized Cutaneous Papules and Nodules in an Asian Man

Image of dome-shaped, red-brown papules and nodules affecting the shoulder (A) and upper extremities (B) of the patient

Xiao-Yong Man, MD, PhD
Min Zheng, MD, PhD
A 43-year-old Asian man presents with 6 months’ development of multiple nonpruritic, nonpainful papules and nodules. He has no relevant medical history and does not take any medications. No family members have similar symptoms. Apart from the lesions, the physical examination is unremarkable. Skin examination reveals disseminated sharply demarcated, dome-shaped, red-brown papules and nodules with a shiny, waxy surface. These 0.1- to 0.8-cm lesions are on his face, scalp, ears, neck, trunk, shoulder (Figure, A), upper extremities (Figure, B), lower extremities including the palms and soles, and scrotum. The mucous membranes and periorbital area are spared. A shave biopsy reveals a yellow appearance of the base of the papule. Hematoxylin-eosin stains reveal a diffuse inflammatory infiltration of the upper and middle dermis with lymphocytes, plasma cells, numerous foamy histiocytoid cells, and a large number of multinucleated cells. Emperipolesis (engulfed lymphocytes) is present within the histiocyte cytoplasm. There is rare nuclear atypia. Electron microscopy shows indented nuclei and emperipolesis in histiocytes. Birbeck granules are not seen.

See the full article for an explanation and discussion.

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