Photo Quiz

Diffuse Papular Eruption

Am Fam Physician. 1998 Oct 15;58(6):1463-1464.

A 36-year-old man presented to his family physician with a large number of slightly yellowish, raised papular lesions, 1 to 3 mm in diameter, on the posterior forearms and the anterior aspects of both legs (Figure 1). He experienced no significant symptoms. A specific clinical diagnosis was not evident, and a biopsy was perfomed to ascertain the nature of the lesions.

Figure 1.

Figure 2 shows the raised bumps on the patient's left posterior forearm. The lesions were diagnosed as histiocytoma, which is seen in Figure 3 at 400 power magnification. The patient was not treated but, shortly thereafter, was admitted because of an episode of acute pancreatitis.

Figure 2.

Figure 3.

Question

Which one of the following is the correct diagnosis, given the patient's history and the physical appearance of the lesions?

A. Keratosis pilaris.
B. Histiocytoma.
C. Molluscum contagiosum.
D. Steroid-induced acne.
E. Type V hyperlipidemia with eruptive xanthomas.

Discussion

The answer is E: type V hyperlipidemia with eruptive xanthomas. Xanthomas are lipid-filled accumulations classically found on the extensor surfaces, as was noted on this patient. They are not necessarily associated with tendons. These lesions can be seen on skin biopsy as areas of fat-rich, foamy histiocytes, hence the original impression of a histiocytoma. The correct histologic diagnosis is “cutaneous xanthomas,” which is comparable to palpebral xanthelasma, a lesion of similar etiology.

The patient was admitted to the hospital for acute pancreatitis secondary to marked elevated serum triglyceride levels. This is not an uncommon finding associated with type V hyperlipidemia (familial lipase deficiency syndrome).

Keratosis pilaris is a variant form of atopic dermatitis. Plugs of desquamated skin partially block the small hair follicles, causing inflammation and sterile pustules outside the follicle. This results in yellowish raised mounds around the hairs, particularly on the arms, legs and trunk, but not in the classic acne-prone areas.

Molluscum contagiosum is a viral “wart” with small, pearly, umbilicated dome-shaped papules. They often occur in crops but would show classic molluscum bodies on biopsy. Steroid-induced acne would look like severe acne and would occur mostly on the face, the upper chest and the back, not on the extensor surfaces.

MARC S. BERGER, M.D., C.M.

P.O. Box 6825

Wyomissing, PA 19610-0825

HERNANDO SALAZAR, M.D., M.P.H.

The Reading Hospital and Medical Center

P.O. Box 16052

Reading, PA 19612

REFERENCES

1. Wyngaarden JB, Smith LH Jr, Bennett JC, eds. Cecil textbook of medicine. 19th ed. Philadelphia: Saunders, 1992:1086.

2. Cotran RS, Kumar V, Robbins SL, eds. Robbins pathologic basis of disease. 4th ed. Philadelpha: Saunders, 1989:1290–1.

3. Habif TP, ed. Clinical dermatology: a color guide to diagnosis and therapy. 2d ed. St. Louis: Mosby, 1990.

4. Sauer GC, Hall JC. Manual of skin diseases. 7th ed. Philadelphia: Lippincott-Raven, 1996.

Contributing editor is MARC S. BERGER, M.D., C.M.

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to afpphoto@aafp.org.

Copyright © 1998 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.