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A Man With Infiltrated Plaques on the Pretibial Area

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A man in his late 20s presented with mildly itchy, erythematous plaques of 3 months’ duration on both legs. The lesions started to appear on the left pretibial region as small papules, which gradually increased in size and coalesced to form bigger plaques. No history of local trauma, prolonged standing, and occupational exposure to mineral dust or recent drug intake was recollected. He was not diabetic. On examination, large, ill-defined, erythematous plaques were present on the pretibial areas extending onto the lateral aspect of both legs. The plaques were surmounted by multiple, discrete atrophic scars. The periphery of the plaques showed increased vascularity in the form of telangiectasias and venous prominences, along with atrophy of the overlying skin (Figure, A). There were no lesions elsewhere on the body. A skin biopsy sample was obtained from the plaque and sent for histopathological examination (Figure, B and C).

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C. Cutaneous sarcoidosis

Skin biopsy revealed multiple, well-formed, compact, noncaseating epithelioid cell granulomas with many multinucleated Langhans type giant cells (Figure, B and C). Special stains for microorganisms including Ziehl-Neelsen and periodic acid–Schiff for acid-fast bacilli and fungus, respectively, had negative results. Intradermal testing with purified protein derivative and mycobacterial culture of the skin biopsy specimen had negative results. Overall features were consistent with a diagnosis of sarcoidosis. A complete blood cell count, biochemistry panel including serum calcium level, and inflammatory markers were normal. A high-resolution computed tomography scan of the chest did not reveal any lymphadenopathy or lung parenchymal changes. Serum angiotensin-converting enzyme level was mildly elevated (69 U/L; reference range, 8-65 U/L; to convert to nanokatals per liter, multiply by 16.667). Electrocardiography, 2-dimensional echocardiography, abdominal ultrasound, Doppler ultrasonography of the lower limbs, and high-frequency ultrasound of the local part did not reveal any abnormality.

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Article Information

Corresponding Author: Dipankar De, MD, Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Sector-12, Chandigarh, Chandigarh 160012, India (dr_dipankar_de@yahoo.in).

Published Online: April 25, 2018. doi:10.1001/jamadermatol.2017.6449

Conflict of Interest Disclosures: None reported.

References
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