History of Present Illness:
A 52 year-old Caucasian female presents to the Washington University Dermatology Clinic with a 4 month history of multiple, painful, firm nodules. Her medical history is notable for psoriasis and psoriatic arthritis previously treated with methotrexate 10 mg per week for the past 15 years and status post one session of infliximab (the last doses of both medications were given 5 months ago). She also has a history of asthma and hypertension. She is currently taking Alendronate, Amlodipine amd Sertraline.
Former armed forces entertainer but without a history of foreign travel, no history of incarceration or known TB contact, former smoker, no alcohol or drug use, owns both cats and dogs.
Numerous one to three cm firm, mobile, sub-cutaneous nodules without epidermal changes in both arms, popliteal fossae, and buttocks. There are also a few thin well-demarcated erythematous micaeous plaques over elbows and knees. See Figure 1 (several dermal nodules are to he right of the pink, scaly, plaque).
CBC and Chem 7 normal, Calcium 9.1, total bilirubin 0.9, AST 21, ALT 22, Alk Phos 108
Elevated ESR 47 and C reactive protein 1.4. Urine culture negative for AFB x 2 and mycology; urine Histoplasmosis antigen was negative. Blood culture negative for bacteria, AFB, Asperigillus, Blastomyces, and Histoplasmosis. Serum cryptococcus antigen was negative.
Skin culture negative for bacteria, AFB, and mycology.
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