Man With an Annular, Dyspigmented, Anesthetic Plaque on the Right Thigh

March 12, 2002

Clinical Presentation

A 53-year-old Indian man living in Dallas, Texas.

The patient presented to the dermatology clinic for evaluation of a large annular lesion on the right thigh that had been present for approximately 6 months. The eruption began as a small papule and steadily increased in size. The patient had noted several additional smaller lesions, which developed in the interim. Empiric treatment for tinea was prescribed by his primary care physician, but there was no improvement. The patient reported that he was otherwise healthy. An extensive review of systems was unremarkable. Although he was currently living in the United States, he was born and raised in India, and returned frequently to visit relatives.

Examination of the right thigh revealed a 15-cm, roughly annular, slightly scaly plaque with a mildly indurated, red-brown edge and a hypopigmented center (Figure 1). Similar smaller lesions were noted on the distal right thigh, left knee, and right ear lobe. Neurologic examination revealed a loss of pinprick and temperature sensation within the lesions.

Annular, scaly plaque on the right thigh (photo courtesy of Dr. High).

A 5-mm punch biopsy was obtained. Histopathologic examination revealed granulomatous nodules of histiocytes surrounded by lymphocytes in the superficial and deep dermis. Peripheral nerve involvement was conspicuous. Fite-Farraco stains showed occasional acid-fast organisms within the granulomas.

  1. Sporotrichosis

  2. Tuberculoid/borderline tuberculoid leprosy

  3. Granuloma annulare

  4. Lyme disease

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