September 2002

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A 54-year-old white female who had traveled to Belize in December 2001 presented to her internist in March 2002 with a lesion on her left forearm. The lesion appeared as a small erythematous papule with surrounding inflammation that involved most of the forearm from the wrist to the elbow. She denied associated pain, itching, fever, chills, mucosal involvement or other symptoms. The lesion was thought to be the result of a spider bite; however, the patient had no recollection of having been bitten in the recent past.

The patient was referred to a dermatologist one week later. Much of the swelling and erythema had resolved, leaving localized erythema around the papule, which was approximately I cm in diameter. A shallow shave biopsy of the lesion was performed and revealed a few epicenters of granulomatous inflammation, none of which contained fungi or AFB. Only minimal dermis was able to be evaluated given the superficial nature of the biopsy. A non-definitive diagnosis of granulomatous dermatitis was made. She was empirically treated with ciprofloxacin and topical ciclopirox, along with an intralesional steroid injection. The patient noted no change after completing these empiric therapies.

During the ensuing 2.5 months, despite an additional course of ciprofloxacin and a repeat steroid injection, the lesion began to ulcerate and weep . On examination, the lesion had increased in size and was a 2.5-cm crusted, ulcerated nodule with a raised, indurated border (Fig. 1). The patient continued to deny any symptoms. A 4-mm punch biopsy was performed at the edge of the lesion.

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