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Subcutaneous Nodules on the Face, Neck,
and Upper Extremities
Philadelphia College of Osteopathic Medicine / Lehigh Valley Hospital
Philadelphia, PA
August, 2002
Presenters: Robert J. Zabel, DO (Resident)
Program Director: Stephen Purcell, DO
Clinical Presentation
Patient: 60 years old Hispanic Female
History
Chief Complaint: Chest pain and shortness of breath
Other Information: A 60 year-old Hispanic female with a
two-year history of idiopathic crescentic glomerulonephritis presented
with chest pain and shortness of breath. Cardiac ischemia was excluded
with serial lab studies and intravenous heparin was started for a
potential pulmonary embolism. On hospital day three, subcutaneous
nodules were noted on her forehead. These nodules rapidly increased in
size and number over a 24-48 hour period. They spread rapidly over the
face, neck, upper trunk, and upper extremities. The subcutaneous nodules
transitioned to exophytic and weeping lesions. On hospital day seven,
she developed a productive cough with blood-tinged sputum and a chest
radiograph showed diffuse bilateral infiltrates. A pulmonary angiogram
was negative for an embolism and anticoagulation was stopped. A
bronchoscopy revealed nodules lining the bronchi and diffuse alveolar
hemorrhage.
Physical Exam
Subcutaneous nodules becoming exophytic and weeping with crust over
face, neck, upper trunk, and upper extremities. There was a 2cm.
hemorrhagic bullous lesion on the left palm. A few oral mucosal ulcers
were present.
Figure 1 to Figure 2. (click image to zoom)
Laboratory Tests
PAS, Gram’s stain, Fite stain, and cultures were
all negative. Leukocytosis with a normal eosinophil count. ESR and CRP
elevated. Positive P-ANCA and C-ANCA
Dermatohistopathology
Microscopic description: Biopsies showed
a large amount of tissue edema, full thickness necrosis of a medium
sized arteriole, neutrophilic infiltrate, and karyorrhexis.
Figure 3 (click image to zoom)
Differential Diagnosis
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