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JAMA Clinical Challenge
December 17, 2014

Pustulonodular Lesion on the Nose

Author Affiliations
  • 1Department of Infectious Diseases, University of Kentucky, Lexington
JAMA. 2014;312(23):2564-2565. doi:10.1001/jama.2014.13527

A 32-year-old man from Kentucky with a history of type 1 diabetes mellitus, hypertension, stage 3 chronic kidney disease, and chronic hepatitis C presented with a 1-month history of swelling and pain over his nose. He originally developed a pustule inside the nares, which gradually spread to involve the nose (Figure 1A). The patient reported no fever, chills, headache, diplopia, cough, dyspnea, or hemoptysis. He did report a history of injection drug use, opioid drug snorting, and tobacco abuse. He also reported working as a gardener and having 2 dogs as pets. Physical examination revealed an erythematous and deformed nose with small pustules and a perforated nasal septum. A complete blood cell count showed a white blood cell count of 19 000 cells/µL; a chemistry panel showed a serum creatinine level of 1.7 mg/dL (150.3 μmol/L) and mildly elevated liver enzyme levels. Results of a human immunodeficiency virus screening test were negative. A computed tomography scan of the head, facial sinuses, and chest showed soft tissue swelling of the nose and several large cavitary lesions in the lungs (all lobes), with multiple bilateral nodular opacities (Figure 1B), but no intracranial lesions.

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