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Dermatology

Multiple Painless Subcutaneous Nodules on the Cheek of an Immunocompetent Man

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

1 Credit CME

JAMA Dermatology

Published Online: November 10, 2021

JAMA Dermatology Clinicopathological Challenge

Article Information and Disclosures

Soufila Kudukkil Thazhathuveettil, MD¹;

Hitaishi Mehta, MD, DNB¹;

Keshavamurthy Vinay, MD, DNB¹

Author Affiliations

¹Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

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A man in his 30s, employed as a painter, presented with multiple painless nodules on his right cheek of 4 years’ duration. He reported episodic breathlessness, cough, and wheezing with expectoration of brownish sputum, exacerbated with exposure to hay dust, in the past 5 years. He also reported recent-onset headache while reading. Physical examination revealed a depressed plaque measuring 6 × 4 cm in the right infraorbital region, surrounded by multiple nodules of sizes ranging from 1 × 1 cm to 5 × 1 cm (Figure, A). The nodules were firm, mobile, and nontender on palpation. Local temperature was normal. There was proptosis of the right eye with mild restriction of extraocular movements on lateral gaze. Examination of the oral cavity revealed dental caries, while gingivolabial sulcus was free on bidigital examination. Nasal mucosa was normal. Respiratory system examination revealed occasional polyphonic wheeze. Chest radiography imaging showed nodular opacities in right upper zone and bronchiectasis. Punch biopsy from 1 nodule was sent for histopathological and microbiological examination (Figure, B and C).

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A man in his 30s, employed as a painter, presented with multiple painless nodules on his right cheek of 4 years’ duration. He reported episodic breathlessness, cough, and wheezing with expectoration of brownish sputum, exacerbated with exposure to hay dust, in the past 5 years. He also reported recent-onset headache while reading. Physical examination revealed a depressed plaque measuring 6 × 4 cm in the right infraorbital region, surrounded by multiple nodules of sizes ranging from 1 × 1 cm to 5 × 1 cm (Figure, A). The nodules were firm, mobile, and nontender on palpation. Local temperature was normal. There was proptosis of the right eye with mild restriction of extraocular movements on lateral gaze. Examination of the oral cavity revealed dental caries, while gingivolabial sulcus was free on bidigital examination. Nasal mucosa was normal. Respiratory system examination revealed occasional polyphonic wheeze. Chest radiography imaging showed nodular opacities in right upper zone and bronchiectasis. Punch biopsy from 1 nodule was sent for histopathological and microbiological examination (Figure, B and C).

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Article Information

Corresponding Author: Keshavamurthy Vinay, MD, DNB, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India 160012 (vinay.keshavmurthy@gmail.com).

Published Online: November 10, 2021. doi:10.1001/jamadermatol.2021.4579

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for granting permission to publish this information. We also would like to thank Rajsmita Bhattacharjee, MD, and Debajyoti Chatterjee, DM, for their contribution in diagnosis and patient management. No additional compensation was provided.

References

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AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 credit toward the CME [and Self-Assessment requirements] of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.