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JAMA Dermatology Clinicopathological Challenge
August 2013

Eruptive, Hard Cutaneous Nodules in a 61-Year-Old Woman

Author Affiliations
  • 1Division of Dermatology, School of Medicine, University of Washington, Seattle, Washington
  • 2in private practice in Phoenix, Arizona
JAMA Dermatol. 2013;149(8):975-976. doi:10.1001/jamadermatol.2013.149a

A 61-year-old woman with a history of chronic renal failure and severe osteoporosis presented to the dermatology clinic complaining of hard, slightly tender nodules ranging in size from 4 to 14 mm on the abdomen, left lower leg (Figure 1), and lower back that had appeared 2 weeks prior to her clinic visit. She had no history of such nodules. Additional physical examination findings included short stature (height of 1.52 m), obesity (especially face and trunk), round face, saddled nose, poor dentition, short neck, broad thumbnails, marked shortening of the fourth digit due to absence of the fourth metacarpal, and brachydactyly of multiple digits with associated racquet nails of the bilateral thumbs (Figure 2). Laboratory tests were performed with the following pertinent findings: serum parathyroid hormone level elevated at 85 pg/mL (reference range, 15-65 pg/mL [to convert to nanograms per liter, multiply by 1.0]) and vitamin D level (25-OH) low at 17.5 ng/mL (reference range, 20-100 ng/mL [to convert to nanomoles per liter, multiply by 2.496]). Serum calcium, ionized calcium, and phosphorus levels were within reference limits; however, the patient had a history of chronic renal failure and low levels of calcium excretion in her urine (urine calcium level low at 60 mg/24 hours [reference range, 100-300 mg/24 hours]).