June 1999

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History: This 40 year old male presented with a several year history of a persistent scaly scalp and chronic headaches. Two months ago he noted bilateral axillary lesions, which were asymptomatic. Review of systems is significant for excessive thirst and frequent urination.

Physical Examination: Scattered erythematous macules and scaly papules were found on the scalp and anterior forehead (Figure A). There is mild tenderness on palpation of the left parietal skull. A 2 cm firm bluish-purple dermal nodule under the left axilla is visible (Figures B) and there is a similar 0.5 cm lesion under the right axilla. There is no palpable adenopathy or hepatosplenornegaly.

Laboratory Findings: Chest x-ray, CBC, liver and renal function tests were within normal limits. Serum osmolarity was markedly increased at 350 milliosmols/L. Skull x-ray series shows limited osteolytic areas within the left parietal calvarium.



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