Vol 144, No. 11, November 2008 Archives Clinical Challenge: You Make the Diagnosis Edematous Nodules on the Extremities of a Febrile Patient REPORT OF A CASE A 75-year-old man with systemic polyarteritis nodosa being treated with oral cyclophosphamide was transferred to our hospital with weakness, persistent fevers, and pancytopenia. During the previous 2 weeks at another hospital, he had been treated with broad-spectrum intravenous antibiotics (ticarcillin clavulanate, metronidazole, vancomycin, and levofloxacin), micafungin, and granulocyte-macrophage colony–stimulating factor in an effort to increase his leukocyte count. Physical examination revealed 5 indurated, edematous nodules on his extremities, 1 near the intravenous catheterization site on his left arm (Figure 1). A tender, stellate, ulcerated plaque was also noted on the hard palate. Laboratory results showed an albumin level of 2.3 g/dL (normal, 3.5-4.5 g/dL); leukocyte count, 0.1 × 103/μL (normal, 4.1-10.9 × 103/μL); hemoglobin level, 8.4 g/dL (normal, 13.5-18.0 g/dL); and platelet count, 10 × 103/μL (normal, 150-440 × 103/μL). After platelet transfusion, a punch biopsy specimen was obtained from 1 of the nodules on the left arm (Figure 2 and Figure 3). (To convert albumin and hemoglobin to grams per liter, multiply by 10; to convert leukocyte count to number of cells × 109/L, multiply by 0.001; to convert platelet count to number of platelets × 109/L, multiply by 1.0.) What is your diagnosis? Figure 1. View a larger version of Figure 1 Figure 2. View a larger version of Figure 2 Figure 3. View a larger version of Figure 3 Please e-mail your diagnosis to dermquiz{at}ama-assn.org. You must include your full name, mailing address, and institutional affiliation in the initial e-mail to be eligible to enter the quiz. The first correct respondent will be acknowledged on this site next month and in print in Archives of Dermatology and will also receive a free copy of The Art of JAMA II. For a complete presentation of this case and an in-depth discussion of the entity, please see next month's edition of the Archives. Congratulations to the winner of our October quiz, CDR Tamara Scalise, MC, USN, Department of Dermatology Naval Medical Center, San Diego, California. The correct answer to our October challenge was pityriasis rotunda. For a complete discussion of this case, see the Off-Center Fold section in the November Archives (Finch JJ, Olson CL. Hyperpigmented patches on the trunk of a Nigerian woman. Arch Dermatol. 2008;144[11]:1509-1514). Next month's quiz will be available on December 15, 2008, at 3 pm Central time.