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AUSTRALIAN DERMATOPATHOLOGY SOCIETY MULTIPLE INDURATED SKIN NODULES

A 37 year old man presented with three skin lesions. The nodule on the volar surface of the left wrist was firm, 2.5 cm in diameter, and had been present for 10 years (Fig. 1). The second lesion over the right scapula was 3 cm in diameter and had been slowly growing for three months. The nodule on the left chest, present for 18 months, measured 2.5 cm in diameter. All three nodules were covered by a thickened, grey-brown hyperpigmented epidermis. They were asymptomatic and non-tender, and on lateral compression exhibited the "dimpling sign" revealing their dermal location. There was no ulceration and no lymphadenopathy. In addition, the patient suffered from falls and severe occipital headaches. Since a cervical spine, injury 18 months prior to presentation he developed coolness and mottling of the upper limbs (worse on the left) associated with parasthesiae, inappropriate sweating and limb pain. Neurological opinion was sought and a provisional diagnosis of basilar migraine and reflex sympathetic dystropy of his upper limbs was suggested. The skin lesions were biopsied and stained with haematoxyin-eosin (Figs. 2 and 3), SlOO (Fig. 4) and NSE (Fig. 5), with original magnification as shown.