Cases from the osler medical service at Johns Hopkins University

Abstract PRESENTING FEATURES: A 45-year-old white man with no notable past medical history and a deep fear of physicians presented to the emergency department complaining of a painless, nonpruritic rash that had been present for several years but had worsened considerably over the past 8 months. The rash started as a red, scaly, flaking patch on his right arm. About 1 year before admission, this patch became raised, and other patches appeared on his arms, legs, and trunk. These patches eventually evolved into hard, raised plaques, some of which developed nodules that became painfully ulcerated with drainage. His other symptoms included fatigue, watery diarrhea lasting 1 month, and weight loss of 35 lbs over the past 6 months. He denied any travel, owning pets, or unusual exposures, and there were no additional specific complaints on review of symptoms. He was taking levofloxacin and sertraline, which were started by a physician whom he saw for the first time 4 days before admission. On physical examination, the patient was a thin, cachetic man who appeared older than his stated age. Vital signs included a temperature of 37.3°C, blood pressure of 132/77 mm Hg, pulse of 80 beats per minute, and normal respiratory rate and oxygen saturation. His examination was notable for enlarged lymph nodes in the inguinal and axillary regions as well as multiple erythematous exfoliative plaques and tumorous ulcerated nodules on his arms, legs, trunk, and back (Figure 1 and Figure 2). There was no rash on the mucous membranes. Laboratory studies revealed a white blood cell count of 18 × 103/μL, a hematocrit of 31.9%, a platelet count of 692 × 103/μL, a mean corpuscular volume of 77.2 fL, a red blood cell distribution width of 14.7%, and an albumin level of 2.6 g/dL. A peripheral blood smear was consistent with a reactive leukocytosis. A chest radiograph showed multiple bilateral masses, and a computed tomographic scan of the chest, abdomen, and pelvis without contrast demonstrated bilateral axillary, pelvic, and inguinal adenopathy in addition to multiple calcified nodules in both lung fields. What is the diagnosis?