A man in his 60s presented as a transfer from an outside hospital. The division of dermatology was consulted for evaluation of lesions on the face, chest, back, and arms that were gradually increasing in size and number over the past year. Physical examination revealed leonine facies with madarosis and an eschar on the nasal dorsum (Figure, A). Red-to-brown dome-shaped papules coalescing into plaques were present on the upper extremities. The lesions were nontender and nonpruritic. Cervical and axillary lymph nodes were palpable. The patient had a muffled voice and reported shortness of breath with exertion. Results of laboratory investigation demonstrated marked leukocytosis with a white blood cell count of 77.5 × 103/uL with 76.5% lymphocytes. No blasts were present on peripheral smear. Computed tomography of the chest, abdomen, and pelvis demonstrated multiple enlarged mediastinal, axillary, subpectoral, abdominopelvic, and inguinal lymph nodes. Small pulmonary nodules were also detected. A punch biopsy was obtained from the right arm (Figure, B, C, and D).