Ulcerating Nodules Progressing Up the Arm of a Construction Worker

W.A. High, MD


December 30, 2002

Case Presentation

A 50-year-old white construction worker.

The patient presented to our dermatology clinic for the evaluation of ulcerating nodules that had been present on his right wrist and upper extremity for 3 weeks. The eruption began as a single erythematous papule of the right ulnar wrist, which later eroded. His primary care physician prescribed a 2-week course of amoxicillin/clavulanic acid, but he noted no improvement. Additional nodules continued to develop proximally on the arm. The patient was otherwise healthy. An extensive review of systems was unremarkable. The patient was employed by a construction firm, and was working on the renovation of a livestock-processing facility in North Texas. The patient did not recall any trauma that predated the initial lesion.

Examination of the right upper extremity revealed multiple, erythematous, ulcerated nodules with proximal extension along the course of draining lymphatics (Figure 1). Extensive regional lymphadenopathy was appreciated. Closer examination of the plaque/nodule on the ventral wrist showed purulent drainage from the center (Figure 2).

Two 6-mm punch biopsies were obtained. Histopathologic examination revealed a granulomatous dermal reaction. Special stains for acid-fast or fungal organisms were negative. Tissue was sent for culture. Aerobic culture showed no growth. Fungal culture revealed a dimorphic fungus. Acid-fast culture revealed no growth after 4 weeks.

What Is Your Diagnosis?

  1. Granuloma annulare

  2. Mycobacterium marinum

  3. Pyoderma gangrenosum

  4. Sporotrichosis

  5. Tularemia

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