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JAMA Dermatology Clinicopathological Challenge
May 2014

Multiple Firm Nodules and Tender, Indurated Plaques

Author Affiliations
  • 1School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
  • 2University of California, Davis, Sacramento
JAMA Dermatol. 2014;150(5):569-570. doi:10.1001/jamadermatol.2013.8734

A man in his 30s with a history of multiple medical conditions, including hypertension, congestive heart failure (receiving chronic diuretic therapy), chronic renal insufficiency, and pulmonary embolus (receiving warfarin therapy), presented with multiple firm nodules that extruded a thin, white, milky fluid within tender, hyperpigmented, indurated plaques on the lower abdomen (Figure, A). He also had numerous smaller nondraining, yellow-white nodules on an erythematous to hyperpigmented base on the bilateral medial thighs (Figure, B). A few scattered firm, yellow-white subcutaneous nodules were also seen on the extensor upper extremities. The lesions appeared approximately 1 year prior to our evaluation of his lower abdomen, where he had injected enoxaparin sodium subcutaneously for 4 days. Six months later, similar lesions appeared on his medial thighs and upper extremities without prior trauma or injection. The patient reported no fevers, chills, joint pain, or swelling. He admitted to social alcohol use. A punch biopsy was obtained of a nondraining yellow-white nodule on the left upper arm (Figure, C).

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