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JAMA Clinical Challenge
February 20, 2018

Ulcerated Nodule of the Fingernail

Author Affiliations
  • 1Department of Dermatology, Weill Cornell Medicine, New York, New York
JAMA. 2018;319(7):713-714. doi:10.1001/jama.2018.0179

A woman in her 60s presented with a 2-year history of an abnormal left second fingernail. A previous biopsy showed a pyogenic granuloma, and she had been treated with curettage and electrodessication. In the few months before presentation, she experienced partial nail loss and her nail had become painful with intermittent drainage. Her medical history was significant for streptococcal glomerulonephritis and 2 prior kidney transplants. Her medications included prednisone, tacrolimus, and mycophenolate mofetil. Physical examination of the left second fingernail showed a tender ulcerated nodule encompassing the nail bed with near-complete nail loss and purulent drainage (Figure 1, left). A nail biopsy was repeated by performing a 4-mm punch through the nail bed. The specimen was analyzed by histopathology with hematoxylin-eosin staining and once again showed a pyogenic granuloma–like response characterized by proliferating blood vessels in a background of fibrosis and reactive plasmacytic infiltration (Figure 1, right). Careful inspection of the pyogenic granulomatous process at higher power demonstrated atypical epithelioid and spindled cells adjacent to blood vessels.

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