Acute painful nodules in a young healthy adult.

47 47 DIAGNOSTIC DILEMMAS IN DERM Case Report A previously healthy 19-year-old man with no significant past medical history presented to the emergency room with six days of worsening fever, headache, and sore throat and a one-day history of tender nodules on the extremities, abdomen, and neck. The patient reported no recent medications, vaccination, illicit substances, or travel prior to this event. He reported no skin problems in the past or family history of skin conditions. Physical examination revealed multiple, tender, 2 to 3cm erythematous nodules distributed haphazardly on the lower extremities, trunk, hands, and neck (Figures 1A–1B). The mucous membranes, genitals, and palms and soles were spared. Punch biopsy from the most prominent and painful nodule on the patient’s left thigh was obtained for histopathological analysis (Figure 1C). Initial laboratory results were significant for elevated erythrocyte sedimentation rate of 92mm/hr (normal: 0–20mm/hr), C-reactive protein of 138.6mg/L (normal: 0–10mg/L), antistreptolysin O of 200units/mL (normal: 0–100 units/mL), and white blood cell count of 8,100/mm (normal: 4,000–12,000/mm) with 75.1% neutrophils (normal: 54–62%). Blood, wound, throat, and cerebrospinal fluid cultures were sent for evaluation.