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May 16, 2011

Painful Swollen Foot—Quiz Case

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Copyright 2011 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2011

Arch Dermatol. 2011;147(5):609-614. doi:10.1001/archdermatol.2011.90-a

A healthy 28-year-old Hispanic woman raised in Bolivia was seen at our dermatology clinic in south Texas for a painful, swollen left foot of several years' duration. She reported gradual swelling of her foot with occasional “bumps draining clear to red fluid.” When asked, she recalled a “nail puncture” 15 years prior. She denied having fever, chills, night sweats, and weight loss and had no prior treatments.

Physical examination revealed a hypertrophic left foot with pink atrophic scars and small nodules, as well as postinflammatory hyperpigmented patches (Figure 1). Radiographs showed global destruction of the bones in her foot with a moth-eaten appearance and multiple cystic lesions. Magnetic resonance imaging revealed diffuse osteomyelitis involving most of the bones of her foot with several round hypointense foci (Figure 2). A deep-tissue biopsy specimen was stained with hematoxylin-eosin and Gomori methenamine silver (Figure 3), and a culture was also sent for analysis.

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