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Aug 2011

Skin-Colored Nodules on the Knuckles —Quiz Case

Author Affiliations
 

SECTION EDITOR: MARY S. STONE, MD; ASSISTANT SECTION EDITORS: SOON BAHRAMI, MD; CARRIE ANN R. CUSACK, MD; SENAIT W. DYSON, MD; MOLLY A. HINSHAW, MD; ARNI K. KRISTJANSSON, MD

Arch Dermatol. 2011;147(8):975-980. doi:10.1001/archdermatol.2011.194-a

A 48-year-old woman presented with a 1-year history of tender, mildly pruritic, slowly enlarging, skin-colored nodules over the dorsal surface of the hands. Her medical history was notable for seronegative spondyloarthropathy, fibromyalgia, insulin-dependent diabetes mellitus, stasis dermatitis, diverticulitis status after colonic resection, and an episode of leukocytoclastic vasculitis presenting as lower extremity pigmented purpura.

Physical examination revealed 1.0-cm skin-colored nodules on the dorsal aspect of the third and fourth proximal interphalangeal (PIP) joints of the right hand (Figure 1) and a 0.7-cm nodule on the third PIP joint of the left hand. Manipulation of the joints underlying the cutaneous lesions elicited discomfort. Recent laboratory studies included negative results for antinuclear antibodies, rheumatoid factor, perinuclear antineutrophil cytoplasmic antibodies, and antineutrophil cytoplasmic antibodies. C-reactive protein level was elevated at 15.8 mg/L (reference range, <7.4 mg/L) (to convert to nanomoles per liter, multiply by 9.524). A punch biopsy specimen was obtained from a nodule on the third PIP joint of the right hand (Figure 2 and Figure 3).

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