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JAMA Oncology Clinical Challenge
March 12, 2020

Painful Cutaneous Plaques on the Lower Legs in a Middle-aged Woman

Author Affiliations
  • 1Department of Dermatology and Venereology, Peking University First Hospital, Beijing, China
  • 2Beijing Key Laboratory of Molecular Diagnosis on Dermatoses, Beijing, China
  • 3Department of Pathology, Peking University First Hospital, Beijing, China
JAMA Oncol. 2020;6(5):772-773. doi:10.1001/jamaoncol.2019.6839

A 47-year-old woman presented with a 7-month history of multiple painful erythematous plaques on her lower legs. The lesions appeared as erythematous nodules on the left leg with tenderness and pruritus and rapidly progressed to both legs. Marked lower-leg edema was noted 20 days prior to the visit. She also had an intermittent fever during the past 3 months that did not respond to antibiotic therapy. The patient’s medical history was unremarkable.

Physical examination revealed ill-defined, indurated erythematous-violaceous plaques on the lower extremities with substantial edema (Figure, A and B). Complete blood cell count revealed a normal white blood cell count with moderate anemia (hemoglobin level, 87 g/L; normal range 115-150 g/L). Additional laboratory tests demonstrated an elevated level of serum lactate dehydrogenase (749 U/L; normal range 100-240 U/L) (to convert to μkat/L, multiply by 0.0167). Quantification of Epstein-Barr virus (EBV) DNA in sera showed a high viral load of EBV in peripheral blood (1 800 000 copies/mL, normal range <500 copies/mL). A skin biopsy specimen was obtained from a violaceous plaque (Figure, C).

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