A 48 year old WM with no significant PMH presented to Barnes Jewish Hospital for evaluation of 18 months of painful skin lesions and intermittent fever. The patient initially presented to his primary care physician with complaints of painful skin lesions on his buttocks, legs, arms, and abdomen and with fevers to 102 º F. The lesions began as small, erythematous papules that evolved into indurated, necrotic nodules over the course of 1 week (Figs 1, 2, and 3). The initial evaluation included routine bacterial cultures, a chest X-ray, and skin biopsy, all of which were non-diagnostic. The skin biopsy revealed only superficial perivascular chronic inflammation. The patient received an empiric treatment of high-dose prednisone without improvement.
These symptoms persisted for several months and the patient once again presented to his primary care physician, at which point a complete blood count was drawn and revealed leukopenia. A bone marrow biopsy with flow cytometry was performed and was non-diagnostic, revealing normal trilineage hematopoiesis without evidence of neoplasm or infection.
The patient next developed anorexia with a 20 pound weight loss, myalgias, and arthralgias, and was treated with broad-spectrum antibacterial antibiotics and prednisone without relief. He received additional evaluation with autoimmune serologies, viral serologies, two additional skin biopsies, two additional bone marrow biopsies, and computed tomography imaging of the chest, abdomen, and pelvis, all of which were non-diagnostic. Skin biopsy revealed panniculitis with granulomatous features, with negative AFB/Fite/GMS stains. Bone marrow biopsies did not reveal any clonal process. At this point, 1_ years after his initial symptoms appeared, he was admitted to Barnes Jewish Hospital for an inpatient evaluation.
Abdomen: No hepatomegaly. + splenomegaly.
Extremities: No edema, + right inguinal lymphadenopathy
Skin: Multiple indurated, necrotic nodules (1-7 cm) on buttocks, trunk, legs, and arms, sparing the face, mouth, and perineum.
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