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JAMA Dermatology Clinicopathological Challenge
December 2017

Coalescing Subcutaneous Nodules

Author Affiliations
  • 1Loma Linda University School of Medicine, Loma Linda, California
  • 2Department of Dermatology, University of California-San Francisco, San Francisco
  • 3Redwood Memorial Hospital, Fortuna, California
JAMA Dermatol. 2017;153(12):1319-1320. doi:10.1001/jamadermatol.2017.2767

A 40-year-old man of Scandinavian descent presented with enlarging, nonpainful upper extremity nodules developing over the preceding 9 months (Figure, A). He was renovating a commercial cannabis grow-house in California at time of onset. He described the construction site as being filled with intoxicating mold. He reported shortness of breath and a 20-pound weight loss. He denied recent travel or aquarium exposure. Most concerning was the inability to use his right upper extremity. Also, he developed a pathological fracture of his right foot (Figure, B). Clinical examination of his forearms revealed several yam-size (4-6 cm), nontender, nonulcerated, boggy subcutaneous nodules in a sporotrichoid pattern and large nodules scattered on his trunk and abdomen. There was no palpable lymphadenopathy or lower extremity lesions. His medical history is significant for diabetes mellitus type 2 and hypothyroidism. Medications included glipizide, metformin, and levothyroxine.

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