Painful nodules on the feet

Presenter: Kenneth T. Kircher, DO

Dermatology Program: Philadelphia College of Osteopathic Medicine / Lehigh Valley Hospital

Program Director: Stephen Purcell, DO

Submitted on: August 29, 2007

CHIEF COMPLAINT: Painful Nodules on Plantar Aspects of Feet

CLINICAL HISTORY: A well-appearing 12-year-old girl presented to the office with exquisitely tender erythematous dermal to subcutaneous nodules on the plantar and lateral aspects of both feet. The patient states that she awoke two days ago with 1-2 slightly raised erythematous nodules on her right foot, that were very tender to walk on. By that afternoon, she had 4-6 lesions on the plantar and lateral sides of both feet. They had become increasingly tender and now prevent ambulation. She denies fever, chills, or other constitutional symptoms. She denies exposure to cold, new medications, any recent illness, or trauma although she did have a prolonged ballet recital the day before. No prior treatments.

PHYSICAL EXAM:
Well appearing 12-year-old girl with exquisitely tender erythematous dermal to subcutaneous nodules on the plantar and lateral aspects of both feet. The rest of her complete cutaneous exam is without other lesions. Pertinent negatives include lack of adenopathy, oral or genital lesions, or dermatographism.

LABORATORY TESTS:

CBC: WBC of 14.2 x 109/L, other indices WNL

DERMATOHISTOPATHOLOGY:

There is a prominent peri-eccrine neutrophilic infiltrate; lymphocytes and a rare eosinophil are also seen. The infiltrate extends to the surrounding tissue but frank abscess formation is not seen. The dermal ductal portion of the eccrine gland is not involved. There is no evidence of syringosquamous metaplasia. There is a mild deep dermal perivascular infiltrate of neutrophils, lymphocytes, and histiocytes. There is no evidence of leukocytoclastic vasculitis. Fungal and bacterial stains are negative.