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SKINDIA QUIZ
Year : 2015  |  Volume : 6  |  Issue : 6  |  Page : 454-455  

SkIndia Quiz 21: Recurrent papulonodular lesions on elbows, fingers and lower leg


1 Department of Dermatology, Medical College and Hospital, Kolkata, West Bengal, India
2 Department of General Medicine, Medical College and Hospital, Kolkata, West Bengal, India
3 Department of Dermatology, Katihar Medical College, Bihar, India

Date of Web Publication17-Nov-2015

Correspondence Address:
Anupama Ghosh
Building - Prerana, 19, Phoolbagan, Kolkata - 700 086, West Bengal
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.164579

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How to cite this article:
Das A, Das I, Ghosh A, Kumar P, Das NK, Gharami RC. SkIndia Quiz 21: Recurrent papulonodular lesions on elbows, fingers and lower leg. Indian Dermatol Online J 2015;6:454-5

How to cite this URL:
Das A, Das I, Ghosh A, Kumar P, Das NK, Gharami RC. SkIndia Quiz 21: Recurrent papulonodular lesions on elbows, fingers and lower leg. Indian Dermatol Online J [serial online] 2015 [cited 2019 Dec 15];6:454-5. Available from: http://www.idoj.in/text.asp?2015/6/6/454/164579

A 35-year-old human immunodeficiency virus (HIV)-negative female patient presented with smooth surfaced umbilicated papulo-nodules of variable sizes of 3 years duration. The lesions were distributed over the extensor aspects of elbows, knuckles, dorsum of fingers and over medial malleolus of left leg [Figure 1]. They progressively increased in size to attain the present status. The lesions were asymptomatic but she complained of occasional sensation of numbness and pain over the fingers; in winter season as well as, on exposure to cold water. The lesions over the right elbow showed evidence of ulceration. She did not complain of any joint pain and had no ocular complaints, sore throat, fever or any constitutional symptoms. Fingernails showed features consistent with distal lateral subungual onychomycosis. There was no history of skin tightening or malar rash. There was neither any sensory loss nor history of similar lesions elsewhere. Past history revealed the occurence of similar lesions many years ago, which responded to pharmacotherapy with dapsone. The lesions used to resolve with atrophic scarring, without any pigmentation. Family history was non-contributory. Systemic examination was unremarkable. Laboratory investigations showed a high absolute eosinophil count of 11,500, with the rest of the hemogram being normal. Urea, creatinine, urinalysis, serum calcium (9.7 g/dl), uric acid (3.2 mg/dl) were all within the normal range. However, alkaline phosphatase (250 IU/L) and serum lactate dehydrogenase (766 IU/L) were raised. Anti-nuclear antibody, anti-neutrophil cytoplasmic antibody, anti-scl 70 antibody, anti-streptolysin O titers, venereal disease research laboratory test, C-reactive protein, rheumatoid factor, slit-skin smear examination, Mantoux test and chest X-ray, were normal. Ultrasonography of abdomen and color doppler of the arterial system of the upper limbs were normal. Bone marrow examination showed eosinophilic myelocyte and metamyelocyte, increased mature eosinophils with blasts lesser than 5% and mild megaloblastoid changes. Histopathology of a nodular lesion showed leukocytoclastic vasculitis and fibrinoid degeneration and neutrophilic infiltrate and fibrosis in the dermis [Figure 2].
Figure 1: Smooth surfaced firm umbilicated papulo-nodules of variable sizes, distributed over the extensor aspects of both elbows (a), knuckles, dorsum of fingers (b) and over medial malleolus of left leg (c), with a close-up view of a lesion (d)

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Figure 2: Photomicrograph of a representative lesion from elbow showing leukocytoclastic vasculitis, fibrinoid degeneration (arrow a) and neutrophilic infiltrate (arrow b) and fibrosis in the dermis (H and E, ×40)

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   References Top

1.
Barnhill RL, Nousari CH, Xu X, Barksdale SK. Vascular diseases. In: Elder DE, Elenitsas R, Johnson BL, Murphy GF, Xu X editors. Lever's Histopathology of Skin. 10th ed. Philadelphia: Lippincott Williams and Wilkins Publishers; 2009. p. 221-2.  Back to cited text no. 1
    
2.
Wahl CE, Bouldin MB, Gibson LE. Erythema elevatum diutinum: Clinical, histopathologic, and immunohistochemical characteristics of six patients. Am J Dermatopathol 2005;27:397-400.  Back to cited text no. 2
    
3.
Sharma V, Mahajan VK, Mehta KS, Chauhan PS, Chander B. Erythema elevatum diutinum. Indian J Dermatol Venereol Leprol 2013;79:238-9.  Back to cited text no. 3
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4.
Cherif F, Abdelmoula FF, Smiri W, Haouet S, Azaiez MI, Osman AD. Erythema elevatum diutinum. A clinicopathologic study of 5 cases. Tunis Med 2005;83:123-6.  Back to cited text no. 4
    
5.
Prabhu S, Shenoi SD, Kishanpuria PS, Pai SB. Erythema elevatum diutinum associated with scleritis. Indian Dermatol Online J 2011;2:28-30.  Back to cited text no. 5
[PUBMED]  Medknow Journal  


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