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Pathology and Laboratory Medicine

Violaceous Nodules on the Right Leg and Foot

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

1 Credit CME

JAMA

Published Online: November 20, 2023

JAMA Clinical Challenge

Article Information and Disclosures

Tai-Li Chen, MD^1,2;

Hao-Kai Chuang, MD^2,3;

Chen-Yi Wu, MD, PhD^1,2,4

Author Affiliations

¹Department of Dermatology, Taipei Veterans General Hospital, Taipei, Taiwan
²Faculty of Medicine, School of Medicine, National Yang Ming Chao Tung University, Taipei, Taiwan
³Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan
⁴Department of Dermatology, National Yang Ming Chao Tung University, Taipei, Taiwan

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An 84-year-old man with dementia presented to a dermatology clinic with a 1-week history of multiple dark violaceous nodules on his right leg and foot. The patient had no fevers, night sweats, fatigue, weight loss, or leg pain or swelling, and no recent history of trauma. Nine months prior to presentation, he had been diagnosed with bullous pemphigoid, which was initially treated with oral prednisolone (40 mg daily for 1 week). His prednisolone dose was reduced by 10 mg per day each week to 10 mg daily, which he had been taking for 8 months. On presentation, his temperature was 36.7 °C (98.1 °F); blood pressure, 120/85 mm Hg; and heart rate, 92/min. Physical examination revealed multiple round, dark brown to violaceous-colored firm nodules on his right leg and 2 nodular masses with hemorrhagic crusts on his right foot (Figure 1). The right dorsalis pedis and popliteal artery pulses were normal to palpation. Laboratory testing revealed a normal complete blood cell count and normal creatinine and liver function test results; results of HIV antibody testing were negative.

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An 84-year-old man with dementia presented to a dermatology clinic with a 1-week history of multiple dark violaceous nodules on his right leg and foot. The patient had no fevers, night sweats, fatigue, weight loss, or leg pain or swelling, and no recent history of trauma. Nine months prior to presentation, he had been diagnosed with bullous pemphigoid, which was initially treated with oral prednisolone (40 mg daily for 1 week). His prednisolone dose was reduced by 10 mg per day each week to 10 mg daily, which he had been taking for 8 months. On presentation, his temperature was 36.7 °C (98.1 °F); blood pressure, 120/85 mm Hg; and heart rate, 92/min. Physical examination revealed multiple round, dark brown to violaceous-colored firm nodules on his right leg and 2 nodular masses with hemorrhagic crusts on his right foot (Figure 1). The right dorsalis pedis and popliteal artery pulses were normal to palpation. Laboratory testing revealed a normal complete blood cell count and normal creatinine and liver function test results; results of HIV antibody testing were negative.

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Article Information

Corresponding Author: Chen-Yi Wu, MD, PhD, Department of Dermatology, Taipei Veterans General Hospital, No. 201, Sec.2, Beitou Dist, Taipei, Taiwan 11217 (chenyiok@gmail.com).

Published Online: November 20, 2023. doi:10.1001/jama.2023.20118

Conflict of Interest Disclosures: None reported.

Additional Information: Drs Chen and Chuang contributed equally to this work. We thank the patient’s son for providing permission to publish the patient’s information.

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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 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.