Abdominal Pain and Subcutaneous Nodules

Abstract

A63-year-oldman is admitted for evaluation of recurrent abdominal pain and a 2-month history of tender nodules on the extremities (Figure 1).HehasahistoryofhepatitisB,hepatocellular carcinoma,and idiopathic pancreatitis. The lesions are initially verypainful andslowto resolve.New lesions tend to appearwith, or immediately after, episodes of acute pancreatitis. Laboratory evaluation reveals elevated levels of serum lipase (2700 IU/L) and amylase (3400 IU/L). Previous treatments have included incision and drainage of a nodule on the right foot as well as oral and intravenous administration of antistaphylococcal antibiotics forpresumedcellulitis. Examinationof the skin reveals erythematous subcutaneous nodules symmetrically distributed on the bilateral lower and upper extremities, primarily on the lower legs and feet. One of the largest nodules has a small amount of yellow, oily discharge. Thepatient is afebrile and reports nausea, vomiting, and arthralgias. Quiz at jama.com Figure 1. Erythematous nodules on foot and ankle of patient.