Presenter: Jonathan Cleaver, Cathy Koger, Peter Knabel, Stephen Plumb
Dermatology Program: Northeast Regional Medical Center
Program Director: Dr. Lloyd Cleaver
Submitted on: Jun 2, 2012
CHIEF COMPLAINT: A 37-year-old Caucasian male presented with a 1-year history of a tender and irritated plaque that would drain fluid located on the left anterior shoulder
Signs and symptoms: Indurated and erythematous tender plaque on the left clavical. Drainage of serosanguinous fluid.
Previous Treatment: No previous therapy
On physical examination a well-circumscribed 1.4cm x 2.5cm tender, red to yellow plaque with telangiectasia was noted on the left anterior shoulder (Figure 1). On further examination, a 2.4cm x 3.0cm indurated, erythematous, subcutaneous plaque was noted on the right lower back (Figure 2).
A CBC, CMP, and a serum protein electrophoresis revealed a WBC of 12.9 K/cmm, blood glucose of 277 mg/dl, HgA1c of 10.8%, and the serum proteins were within normal range. The patient was referred to hematology and oncology where they recommended a CT scan of the chest, abdomen, pelvis, a serum immunoelectrophoresis, Beta 2 microglobulin, quantitative IgG, IgA, IgM, a 24hr urine for urine protein electrophoresis and urine immunoelectrophoresis. All these tests were within normal limits.
Histologically the sections demonstrated a relatively unremarkable epidermis. The dermis showed numerous necrobiotic foci surrounded by lymphocytes and histiocytes. Multiple xanthomatous cell and areas of cholesterol clefts were appreciated
2. Basal Cell Carcinoma
3. Granuloma annulare
4. Necrobiotic Xanthogranuloma
5. Foreign-body granuloma