Painful nodules on the feet

Presenter: Kenneth T. Kircher, DO (Resident)
Dermatology Program: Philadelphia College of Osteopathic Medicine / Lehigh Valley Hospital
Program Director: Stephen Purcell, DO
Submitted on: Aug 29, 2007

CHIEF COMPLAINT:  Painful Nodules on Plantar Aspects of Feet

CLINICAL HISTORY:

Signs and symptoms:  The patient states that she awoke two days ago with 1-2 slightly raised erythematous nodules on her right foot, that were very tender to walk on. By that afternoon, she had 4-6 lesions on the plantar and lateral sides of both feet. They had become increasingly tender and now prevent ambulation. She denies fever, chills or other constitutional symptoms. She denies exposure to cold, new medications, any recent illness or trauma although she did have a prolonged ballet recital the day before.

Previous Treatment:  None

PHYSICAL EXAM:

Well appearing 12 year old girl with exquisitely tender erythematous dermal to subcutaneous nodules on the plantar and lateral aspects of both feet. The rest of her complete cutaneous exam is without other lesions. Pertinent negatives include lack of: adenopathy, oral or genital lesions or dermatographism.

LABORATORY TESTS:

CBC
WBC ?14.2 x 109/L, other indices WNL

DERMATOHISTOPATHOLOGY:

Pathology Figure #1. There is a prominent peri-eccrine neutrophilic infiltrate; lymphocytes and a rare eosinophil are also seen. The infiltrate extends to the surrounding tissue but frank abscess formation is not seen. The dermal ductal portion of the eccrine gland is not involved. There is no evidence of syringosquamous metaplasia. There is a mild deep dermal perivascular infiltrate of neutrophils, lymphocytes and histiocytes. There is no evidence of leukocytoclastic vasculitis. Fungal and bacterial stains are negative.

 

(Pathology Figure #1 – pathology pictures are being referenced in the bibliography.)

Pathology Figure#2. Immunostaining demonstrates the eccrine glands within the infiltrate.

(Pathology Figure #2- pathology pictures are being referenced in the bibliography.)

DIFFERENTIAL DIAGNOSIS:

1.   Plantar urticaria
2.   Atypical erythema nodosum
3.   Idiopathic recurrent palmoplantar hidradenitis
4.   Chilblains


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