A 30-Year-Old Man With a 2-Year History of Rash

Adam R. Taintor, MD

Disclosures

May 18, 2009

Patient

The patient is a healthy 30-year-old Hispanic male.

History

A native of Guadalajara, Mexico, the patient has lived in the United States for 15 years.

Prior to his presentation, he had a 2-year history of a rash. The rash began on his left lower leg as a small pink spot. It subsequently turned white and then slowly spread with an advancing pink border. Two months prior to presentation, he had complaints of a burning sensation on the left forearm. The patient presented to a community dermatologist for evaluation of "vitiligo" and was started on ketoconazole cream for tinea versicolor. When he did not respond, a biopsy was obtained.

Physical Examination

On exam, the patient appeared to be in excellent general health. His left upper arm, chest, back, and abdomen had scattered small and larger 1- to 8-cm patches with hypo- to depigmented centers and surrounding pink borders (Figures 1-3).

Figure 1.

Patches on the patient's back.

Figure 2.

Patches on the patient's arm.

Figure 3.

Patches on the patient's chest.

The left medial ankle was remarkable for 2 small 4- to 6-mm pink nodules as well as decreased sensation to light touch (Figure 4).

Figure 4.

Nodules on the patient's ankle.

There were no frank areas of anesthesia to light touch within the areas of depigmentation. No palpable wiry or cord-like nerves were noted on examination of the arms, legs, or neck, and no facial involvement was observed.

Histopathology

On H&E stain (Figures 5-7), there were disorganized aggregates of lymphocytes and foamy histiocytes at all levels in the dermis, but they were most extensive in the upper dermis with a Grenz zone. The infiltrate involved several cutaneous nerves, with multiple foci of perineural proliferation.

Figure 5.

Low-power view of the biopsy specimen.

Figure 6.

Medium-power view of the biopsy specimen.

Figure 7.

High-power view of the biopsy specimen.

What is your diagnosis?

  1. Erythema induratum

  2. Secondary syphilis

  3. Lepromatous leprosy

  4. B-cell lymphoma cutis

View the correct answer

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