| Introduction: |
| A 44 year old woman was evaluated by the inpatient dermatology consultation service for tender nodules on the hands and elbows of 1 month duration. |
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| History: |
| One month prior to admission she developed a progressive cough, shortness of breath and hemoptysis which did not improve with 3 weeks of oral levofloxacin given for presumed pneumonia. Several weeks before admission she developed dark spots on her elbows and the back of her hands.
Two years earlier she had her mitral valve replaced because of severe mitral stenosis. Shortly afterward she had a Nissen fundoplication for treatment of gastroesophageal reflux disease. Chronic cough was noted atleast 1 year before the current admission. |
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| Clinical
Presentation: |
| On examination she had violaceous tender nodules with central crusts on the extensor surfaces of the elbows and over the metacarpal and proximal interphalyngeal joints. Her mucous membranes and lacrimal glands were normal. She had no purpura, periungual telangiectasias, organomegaly, or lymphadenopathy. |
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| Pathology: |
| Transtrachial lung biopsy showed alveolar macrophages and mixed inflammatory cells with numerous eosinophils. Special stains were negative for acid fast bacteria, Pneumocystis carinii, Cytomegalovirus, virus, bacteria, and fungi.
Skin biopsy demonstrated an ill defined area of palisading granulomatous dermatitis with central degeneration of collagen, prominent leukocytoclasis and rare eosinophils. |
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| Question
1: |
| What is the differential diagnosis?
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| Question
2: |
| What further evaluation will this patient require?
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| Question
3: |
| How would you treat this patient? |
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| Question
4: |
| What is her prognosis? |
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