Presenter: Paul Ross, D.O., Mark D. Garcia, D. O.

Dermatology Program: Northeast Regional Medical Center

Program Director: Lloyd J. Cleaver, D.O.

Submitted on: Apr 21, 2002

CHIEF COMPLAINT:  Erythematous Nodules on the Extremities

CLINICAL HISTORY: A 54-year-old white female presents for in-hospital consultation with erythematous nodules on her forearms bilaterally and her left medial thigh for 2 days duration. The patient reports some associated tenderness and denies any associated pruritis, burning, or discharge. She has had no previous occurrence of similar lesions. The patient reports having received chemotherapy for recurrent breast carcinoma one week prior to admission. She also reports receiving Neupogen (filgrastim) after chemotherapy. Her other medications include Herceptin (trastuzumab), Taxotere (docetaxel), Xeloda (capecitabine), Coumadin, and Vioxx.

PHYSICAL EXAM:
A well-nourished Caucasian female in no acute distress. Three erythematous nodulovesicles ranging from .5 to 1.3 cm are noted on the forearms bilaterally and a single similar lesion is found on the left medial thigh. Lesions were tender to palpation. No axillary, epitrochlear, or inguinal adenopathy was noted. Oral mucosa is WNL.

LABORATORY TESTS:

WBC 0.9
Hgb 9.0
Hct 26.5
Plt 117,000
ESR 80

DERMATOHISTOPATHOLOGY:

Marked edematous epidermis with subcorneal and intraepidermal blister formation. Reticular and mid dermis shows intense inflammatory infiltrate of neutrophils with scattered eosinophils and mast cells. Some leukocytoclasis is present with nuclear dust, but leukocytoclastic vasculitis is not seen.

DIFFERENTIAL DIAGNOSIS:

1.   Pyoderma Gangrenosum
2.   Sweet’s Syndrome
3.   Bullous Drug Eruption
4.   Infectious Pyoderma