History: A 46 year-old African-American man presented
with a 4-month history of worsening, intermittent coughs and fevers,
and a several week history of skin nodules on the left hand and
face. He had been treated at an outside hospital for pneumonia.
During that earlier outside hospitalization, a chest radiograph
had revealed a pulmonary mass concerning for malignancy, but the
patient refused pulmonary biopsy and was lost to follow-up.
Past Medical History: GERD.
Medications: ibuprofen, ranitidine, prochlorperazine.
Family History: lung cancer.
Social History: 20 pack-year smoking habit, rare alcohol consumption.
Travel History: only in the Midwest.
Physical Examination: T 36.7ºC. BP 104/70. P 74.2 verrucous, draining, ulcerated plaques on chin (Figure 1).Erythematous, edematous, draining, ulcerated plaque on left dorsal hand (Figure 2). Remainder of skin examination unremarkable. No lymphadenopathy.
Admission Laboratory Data: WBC 8.3 with normal differential. H/H: 11.5/35.2Plt: 362. HIV negative. RPR negative
CXR: Left perihilar and suprahilar opacity.
X-ray of hand: Diffuse destruction of the second metacarpal with pathologic fracture (Figure 3).
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