Green Pigmentation on the Palms and Soles

Abstract

Aman inhis50spresentedwithabrupt-onsetasymptomaticgreen and brown pigmented lesions on both his palms and soles (Figure, A). He had had progressive jaundice for a month and was recently diagnosedashavingadvanced intrahepaticcholangiocarcinoma.The cutaneous eruption developed 3 days after a high-grade fever during admission for palliative endoscopic retrograde cholangiopancreatography with metallic stent insertion. The investigation for cause of fever showed influenza A infection. He denied history of contact with any greenish substances on his palms and soles during admission. His sweat was colorless. Physical examination revealed generalized marked jaundice and bilateral symmetrical greenish brown macules and patches on hyperkeratotic palms and soles. The potassium hydroxide examination and Gram stain results were negative for any organisms. Laboratory tests showed a total to direct bilirubin level of 32.7/ 25.5 mg/dL; aspartate aminotransferase level of 93 U/L; alanine aminotransferase level of 82 U/L; and alkaline phosphatase level of 973 U/L. (To convert bilirubin to micromoles per liter, multiply by 17.104; to convert asparatate aminotransferase, alanine aminotransferase, and alkaline phosphatase to microkatals per liter, multiply by 0.0167.) Figure, B, shows the dermatoscopic finding of peeling skin. An incisional biopsy specimen from a nondesquamated greenish brown patch on the left palm, 1 day after the appearance of lesions, was stained with hematoxylin-eosin (Figure, C). What is your diagnosis?