5 Q ~ Subcutaneous Granulomatous Nodules as a Presenting Feature IdlEof Common Variable Immunodeficiency Shelley K Watters, Michael Christian Zacharisen, Jordan N Fink Medical College of Wisconsin, Milwaukee, WI While visceral granulomas are common in patients with CVID, isolated cutaneous granulomas are unusual. Subcutaneous nodular granulomatous lesions have rarely been reported in primary immunodeficiency. We report a 37-year-old woman whose diagnosis of CVID was preceded by a 7 year history of episodic subcutaneous nodules. Her presentation is unusual in that these sterile subcutaneous granulomas antedated the diagnosis of CVID. She presented with tender subcutaneous nodules on the extensor surfaces of all extremities. Nodules on the anterior tibial region ulcerated and required intravenous antibiotics. Several biopsies revealed granulomas but failed to yield a definitive diagnosis. Diagnoses of erythema nodosum, sarcoid and rheumatoid nodule were entertained, but biopsies were not completely consistent with any of these. She was treated with oral steroids with temporary resolution of the lesions, but they recurred after steroids were discontinued. Shortly after the development of the nodules, she began to experience frequent sinopulmonary infections eventually leading to laboratory testing which revealed panhypogammaglobulinemia. Pneumococcal antibody levels were low and did not increase after pneumococcal vaccination. A bone marrow biopsy was normal. A repeat biopsy of the skin lesions revealed pannicular palisading granulomatous inflammation with the differential diagnosis including rheumatoid nodule, but subcutaneous granuloma annulare was favored. She was diagnosed with CVID and started on monthly IVIG 400mg/kg. She initially noted a dramatic improvement in her infections as well as resolution of the nodules. After 6 months of IVIG, however, both the sinopulomonary infections and the nodules recurred. Since there have been reports of complete resolution of cutaneous granulomatons lesions with high dose IVIG, her dose has recently been increased to 600 mg/kg. Although infrequent, skin findings associated with CVID are diverse in their clinical appearance. Patients may present with generalized erythematous maculopapular eruptions, erythematous scaly lpules on the extremities, excoriated papules and ulcers, ttions and lesions resembling Gottron's papules. Culaaicroorganisms are routinely negative. Histology of the lenging as these granulomas do not readily conform to a disading granulomas are frequently described, but the ,gical changes may include nonnecrotizing epithelioid zl-like), caseating (tuberculoid) granulomas and necroAtypical granulomatous cutaneous and subcutaneous ' in the setting of frequent infections, should prompt an modeficiency.