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JAMA Dermatology Clinicopathological Challenge
January 2019

Necrotic Plaque on the Distal Nose With Diffuse Crateriform Nodules

Author Affiliations
  • 1Department of Dermatology, University of Virginia, Charlottesville
  • 2Department of Pathology, University of Virginia, Charlottesville
JAMA Dermatol. 2019;155(1):113-114. doi:10.1001/jamadermatol.2018.2552

A 33-year-old white man presented with a 5-month history of a progressively necrotic plaque on the nose and scattered nodules on the extremities. The plaque first appeared as a small inflammatory papule on the left nostril. Shortly thereafter, the patient was hospitalized at an outside facility for multifocal pneumonia. He was also treated for a methicillin-resistant Staphylococcus aureus infection of his nose. Despite antibiotic therapy, the papule continued to grow and ulcerate and eventually became necrotic (Figure, A). One month before presentation at our facility, the patient began developing erythematous papules on his arms and legs. The papules enlarged and ulcerated. Some of them healed spontaneously with poxlike scars. He had no recent history of travel. At admission, the patient was tachycardic and febrile to a temperature of 38.5°C. Routine laboratory testing revealed normocytic anemia (hemoglobin, 7.7 g/dL [to convert to grams per liter, multiply by 10]). Shave biopsies of necrotic nodules on the left arm and left cheek (Figure, B-D) and, later, an excisional biopsy of a cervical lymph node were performed. Head computed tomography demonstrated a soft-tissue mass that encased the nasal bone and extended into the right maxillary sinus and left nasal cavity. Chest computed tomography showed bilateral pulmonary nodules. Physical examination revealed a necrotic plaque with surrounding erythema on the distal nose (Figure, A). A 1 × 1-cm crateriform papule with central necrosis was present on the left malar cheek. Multiple nodules with central, dry necrosis and areas of poxlike scarring were scattered across the extremities. Slight contractures of his fingers were also noted.

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