February/March 2002


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History:

A 60-year-old African American male presented with a 4-month history of a rapidly enlarging patch of alopecia on the vertex of the scalp. Three years prior to this presentation, he was evaluated for hand swelling and pain. Radiographs of his hands revealed asymmetric nodular soft tissue swelling, narrowed joint spaces and sclerotic and lucent lesions.

Seventeen years prior to the current presentation, he was evaluated for a pulmonary mass. Thoractomy preformed at that time yielded non-caseating granulomas. He was given a diagnosis of pulmonary sarcoidosis, but required no therapy.

The affected area was only intermittently and mildly pruritic. He also reported that his hands hurt, but this had been stable and of only minor inconvenience. He denied cough, shortness of breath, dysphagia, eye pain, fever, night sweats or weight loss.

Physical Examination: The patient had an 8-cm patch of alopecia with fine scale and scattered broken hairs (Fig. 1). There were no pustules or fluctuance. His hands were diffusely enlarged with sausage digit deformities (Fig. 2). Microscopic examination of the scale after potassium hydroxide preparation did not demonstrate fungal elements. Additionally, a fungal culture from the scalp was negative.

 

Laboratory Results: A comprehensive laboratory examination was within the normal reference limits and consistent with values obtained three years prior. His chest x-ray demonstrated no evidence of active cardiopulmonary disease. However, bilateral hilar prominence was noted.

A 3mm-punch biopsy was obtained from the affected area of the scalp.


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