A50-year-old heterosexual man presented to the emergency department for evaluation of a diffuse rash that started 10 weeks prior to hospital admission. He reported that the lesions began as small (0.3 cm), pink papules on his upper extremities, which progressed into large (3 cm), red, annular, plaque-like lesions that developed a thin scale within several days of onset. Subsequently, the lesions spread to his scalp, face, trunk, genitals, and lower extremities. He reported subjective fevers, chills, occasional drenching night sweats, and a 10-lb weight loss. Simultaneous with the onset of the skin lesions, he had an intermittent nonproductive cough, without dyspnea. Six weeks prior to presentation, he described the onset of sinus congestion with occasional epistaxis and left eye conjunctivitis, at which time he received a course of antibiotics. He denied any significant medical history. He also denied tobacco use, animal exposures, or recent travel. He worked as a cartographer in Colorado.
On physical examination, he had a temperature of 38.1°C and a normal room air oximetry result. The left conjunctiva was injected with an erythematous plaque around the lateral canthus. The nasal mucosa had an area of septal ulceration. There were a number of anterior cervical, posterior cervical, and inguinal lymph nodes that were nontender and < 1 cm. He had inspiratory crackles at the right base, Skin examination revealed multiple 0.2- to 0.3-cm nontender, pink papules on the lower extremities and on the ventral aspect of the shaft of the penis. There was no penile discharge. The arms, face, scalp, and trunk had larger (2 to 5 cm), red, annular, scaling, plaque-like lesions. The rash did not involve his palms or soles (Fig 1). review
Notable laboratory data included the following: WBC count, 8.9 cells/^L; hematocrit, 37%; platelets, 347,000/^L; total protein, 6.9 mg/dL; albumin, 3.1 mg/dL; total bilirubin, 0.6 mg/dL; alanine aminotransferase, 33 IU/L; alkaline phosphatase, 162 IU/L (normal range, 50 to 136 IU/L); lactate dehydrogenase, 111 IU/L (normal range, 100 to 175 IU/L); glucose, 100 mg/dL; and creatinine, 2.4 mg/dL. Urinalysis revealed the following: protein, 100 mg/ dL; glucose, 100 mg/dL; WBCs, 0 to 1 per high-power field; RBCs, 3 to 4 per high-power field; and hyaline and granular casts. A radiograph and a CT scan (Fig 2) of the chest showed multiple bibasilar pulmonary nodules.
Figure 1. Photograph of the skin lesions at presentation.
Figure 2. Chest radiograph (top) and CT scan (bottom) demonstrating multiple bibasilar pulmonary nodules measuring up to 1.5 cm in size.