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Acquired Ichthyosis in a Middle-aged Woman

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

An African American woman in her 30s presented with a 6-month history of 1-cm to 2-cm erythematous and scaly plaques on her lower legs associated with 30-kg weight loss. The plaques began around her ankles and spread proximally, reaching the upper thighs by the time of presentation. She also noted new lesions on her arms and abdomen in the preceding weeks. The eruption was asymptomatic, and the plaques were preceded by lower extremity edema and weakness, resulting in difficulty ambulating and frequent falls. The patient also reported allodynia, tingling, and numbness in her lower legs. She took no medications and her medical history was significant for a first-trimester miscarriage. She was a schoolteacher and had not traveled outside of the country in the past 10 years.

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A. Plaque and ichthyosiform sarcoidosis

Histopathologic evaluation of the 2 different lesions showed well-formed epithelioid granulomas distributed around neurovascular bundles without evidence of vasculitis (Figure, C and D). Examination under polarized light revealed no foreign material. No microorganisms were identified with the use of special stains, including acid-fast bacilli, Fite, and periodic acid-Schiff stains. Results of in situ hybridization for Epstein-Barr virus were negative. Computed tomography of the thorax and abdomen showed bulky hilar, mediastinal, and retroperitoneal lymphadenopathy. An angiotensin-converting enzyme level was found to be 145 U/L (reference range, 8-53 U/L; to convert to nanokatals per liter, multiply by 16.667). Findings on electrocardiography, echocardiography, and urinalysis were normal. Thyroid-stimulating hormone and 25-hydroxyvitamin D levels were normal, but an increased level of 1,25 dihydroxyvitamin D was noted.

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Article Information

Corresponding Author: Karl M. Saardi, MD, Department of Dermatology, MedStar Georgetown University Hospital–Washington Hospital Center, 110 Irving St NW, 6th Floor GME Office, Washington, DC 20010 (ksaardi@gmail.com).

Published Online: May 13, 2020. doi:10.1001/jamadermatol.2020.1081

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information.

References
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