Tender plaques of the trunk

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

CLINICAL HISTORY:

Signs and symptoms:  Indurated and erythematous tender plaque on the left clavical. Drainage of serosanguinous fluid.

Previous Treatment:  No previous therapy

Other information:

PHYSICAL EXAM:

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).

 

Left clavical

 

Right lower back

LABORATORY TESTS:

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.

DERMATOHISTOPATHOLOGY:

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

 

Low power

 

High power

DIFFERENTIAL DIAGNOSIS:

1.   Sarcoidosis
2.   Basal Cell Carcinoma
3.   Granuloma annulare
4.   Necrobiotic Xanthogranuloma
5.   Foreign-body granuloma


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