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JAMA Dermatology Clinicopathological Challenge
November 09, 2016

Painful Papulonodule on the Foot of a Patient With Human Immunodeficiency Virus

Author Affiliations
  • 1James H. Quillen College of Medicine, East Tennessee State University, Johnson City
  • 2Department of Dermatology, University of Iowa Hospitals and Clinics, Iowa City
  • 3Department of Pathology, University of Iowa Hospitals and Clinics, Iowa City
JAMA Dermatol. Published online November 9, 2016. doi:10.1001/jamadermatol.2016.3899

A man in his 50s with diagnoses of human immunodeficiency virus (HIV) infection, hepatitis B, and latent tuberculosis presented with a slow-growing nodule on the left foot. The lesion started 1 year prior as a tender red nodule on the medial aspect of his first metatarsophalangeal joint, which would enlarge and become painful approximately once a month (Figure, A). The patient reported that with manipulation, a clear-to-yellow material drained from the lesion. The patient denied any purulent drainage, additional skin lesions, fever, chills, or other systemic symptoms. His medications included efavirenz–emtricitabine–tenofovir disoproxil fumarate for his HIV, with the most recent absolute CD4-positive cell count of 341 cells/mm3 (reference range, 263-2045 cells/mm3), and recent completion of an 8-month course of isoniazid treatment after being exposed to tuberculosis. Physical examination demonstrated an erythematous papulonodule without warmth or drainage on the dorsal left great toe. No lymphadenopathy was appreciated. A punch biopsy was performed (Figure, B, C, and D) to help establish the diagnosis.

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