Painful Necrotic Nodules in an Immunocompromised Patient—Quiz Case

Abstract

A 59-year-old African American woman with a history of hypertension and diabetes mellitus was referred to the dermatology department for treatment of a pruritic skin condition of 1 week’s duration that began on her hands and spread to involve the arms, trunk, and lower extremities. She later developed blisters on the soles of her feet and had difficulty walking because of the pain. Her medications includedpioglitazonehydrochloride,hydrochlorothiazide, sucralfate, lisinopril,andhydrocodonewithacetaminophen. Physical examinationrevealedseveral erythematous scaly papules coalescing into plaques on the trunk, lower extremities, and dorsum of the hands (Figure 1) and hyperkeratotic scaly plaques on the palms and soles. The patient also had few erosions and tense bullae on her upper and lower extremities (Figure 2; the arrow indicates the tense bulla on the right medial palm). A biopsy of the left lower extremity with a tense bulla was performed, and a specimen was sent for hematoxylin-eosin staining (Figure 3). A subsequent biopsy specimen of the right upper arm was sent for direct immunofluorescence. Findings from a complete blood cell count, liver function tests, rapid plasma reagin, and human immunodeficiency virus tests were within reference range or negative for disease. However, she was positive for the hepatitis C antibody. What is your diagnosis?