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October 20, 2008

Multiple Pink Papules in the Setting of Arthritis and Fever—Diagnosis

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Copyright 2008 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2008

Arch Dermatol. 2008;144(10):1383-1388. doi:10.1001/archderm.144.10.1383-h

Histologic examination revealed a diffuse interstitial dermal infiltrate of mononucleated and multinucleated cells, the latter with a ground-glass appearance. Immunoperoxidase-stained sections of the cellular infiltrate were positive for CD68 and negative for S-100 protein, CD1a, and CD31. The patient was admitted for workup of suspected malignant neoplasm and infection. Blood and synovial cultures grew methicillin-resistant Staphylococcus aureus, and the patient improved when treated with intravenous antibiotics, with an unexpected, though notable, decrease in the size and tenderness of cutaneous lesions. Computed tomographic scans, however, revealed extensive lymphadenopathy and presumed metastases in the lungs, liver, pancreas, and several osseous structures. Given the patient's newly diagnosed hepatitis C infection, a liver mass specimen was biopsied. Postoperatively, the patient developed severe hemodynamic instability with uncontrollable perihepatic bleeding, and he died shortly thereafter. Autopsy findings revealed multiple foci of hepatocellular carcinoma with extensive necrosis, mesenteric lymphadenopathy measuring up to 15 cm, and a cirrhotic liver with right lateral lobe laceration. The cause of death was hypovolemic shock owing to massive hemorrhage.

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