September 2006








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

Admission Radiography:
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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