A woman with pruritic papules in her tattoo

Abstract

A 46-year-old woman presented with a 3-month history of pruritic, burning papules within a 10-year-old tattoo. The physical examination revealed a large, multicolored tattoo across her back with discrete papules in the black portion (Fig 1). Tender, red subcutaneous nodules were present on the anterior aspect of the lower legs. The patient developed systemic symptoms, including low-grade fevers, fatigue, chest pain, arthralgias, shortness of breath, and cough. A computed tomography scan of the chest was performed, and it revealed bilateral hilar lymphadenopathy. Pertinent laboratory tests include an elevated serum angiotensin-converting enzyme titer at 80 U/L (reference range, 8-53 U/L). Punch biopsy specimens were obtained from the mid-back tattoo and a left dorsal thumb papule (Fig 2). 1.The biopsy specimen of a red subcutaneous nodule on the anterior aspect of the lower leg reveals a septal panniculitis with Miescher granulomas consistent with which of the following? A.Infectious panniculitis B.Darier–Roussy sarcoidosis C.Subcutaneous T-cell lymphoma D.Erythema nodosum E.Lupus profundus 2.What is the patient's most likely diagnosis? A.Löfgren syndrome B.Blau syndrome C.Heerfordt syndrome D.Mikulicz syndrome E.Lupus pernio 3.Patients with this condition are most likely to have which of the following laboratory abnormalities? A.Decreased angiotensin-converting enzyme level B.Hyperkalemia C.Hypocalcemia D.Hyponatremia E.Hypercalcemia