`Right hand and arm rash`

Authors: Michele Goldhagen, MD

Stacy Nunberg, MD

Alan M. Freeman, MD

Affiliations: Department of Emergency Medicine

Long Island Jewish Medical Center and

Albert Einstein College of Medicine

(MG, SN, AMF)

Photographic Critique: Michael A. Morris

University of Arkansas Medical School

Little Rock, AR

View Photograph

Chief Complaint:

Right hand and arm rash.

History of present illness:

A 41 year-old, right-hand dominant, Caucasian male office worker presents for evaluation of multiple clusters of erythematous papules on the dorsum of his right hand. He states that the lesions began as an isolated nodule three months prior to this evaluation. He did not seek medical attention initially, and treated the lesions with soap, water, and cortisone cream. However, when the nodules increased in size and additional nodules appeared, the patient sought the advice of his family physician, who placed the patient on cefadroxil. After completion of a two week course of treatment, the number of lesions increased and gradually spread proximally to his axilla.

Constitutional symptoms, including fevers, chills, night-sweats, productive or non-productive cough, fatigue, and weight-loss are absent. The patient denies risk factors for immunosuppressive disorders. The patient takes no other medications, and has no history of drug allergies. Further discussion reveals that his hobbies include keeping and caring for three tropical fish tanks.

Physical Examination:

This white man is in no acute distress. The patient's vital signs are normal. Examination of the dorsum of the right hand reveals multiple clusters of non-tender, indurated papules on erythematous bases. No swelling, warmth, or drainage is noted. The right, volar forearm contains multiple, discrete, erythematous, non-tender, non-fluctuant, subcutaneous nodules that measure approximately 1 centimeter in diameter. Several erythematous, non-tender, fluctuant, subcutaneous nodules that are larger than those on the forearm are seen on the proximal aspect of the right arm. No axillary adenopathy is noted, although phlebitis with palpable cords cover the entire arm.

Laboratory and additional tests:

Radiographs of the right upper extremity reveal only soft tissue swelling. A biopsy and fluid aspirate from a nodule on the dorsum of the right hand are obtained and submitted for AFB, silver stain, H + E, gram stain, fungal a