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December 2003

Tender Subcutaneous Nodules in a Patient With AIDS—Quiz Case

Author Affiliations


Arch Dermatol. 2003;139(12):1647-1652. doi:10.1001/archderm.139.12.1647-a

A 57-year-old man with advanced AIDS, arthritis, and bipolar disorder presented with mania and an acute onset of multiple tender subcutaneous nodules. A recent outpatient workup, for peripheral eosinophilia of 46% and pruritis, was unrevealing. The patient's most recent CD4 cell count was 3/µL, and his human immunodeficiency viral load was 236 486 copies/mL. He was taking oral sulfamethoxazole-trimethoprim (Bactrim) for pro-phylaxis of Pneumocystis carinii pneumonia. Examination revealed a cachectic man with a low-grade fever and numerous raised, 1- to 2-cm tender nodules distributed on his trunk, extremities, and buttocks. Most of the nodules were erythematous and had central crusted ulcers. Some coalesced to form a cordlike structure that extended from just above the patient's right areola to his sternal notch (Figure 1). Many molluscum contagiosum lesions and herpetic skin ulcers were also evident. A computed tomographic scan of the chest also demon-strated multiple pulmonary nodules. A biopsy specimen from one of the arm nodules revealed a gram-positive bacterial abscess that yielded methicillin sodium–sensitive Staphylococcus aureus on culture. After 2 days of intravenous oxacillin sodium therapy, all the cutaneous lesions had nearly resolved, except for the cordlike nodule on the right side of the chest wall. Further questioning revealed that this nodule had been slowly enlarging over a 3- to 4-week period and, at one point, drained a white, milky fluid. A biopsy of the chest lesion was performed (Figure 2 and Figure 3).