A 40-year-old man presented with multiple skin lesions that developed three weeks earlier. He first noticed an erythematous, raised, painful nodule in his right axilla. Similar lesions appeared across his trunk, back, arms, and legs. He was initially evaluated in the emergency department and was treated with a steroid and a 10-day course of doxycycline, with no improvement.

The patient reported unintended weight loss over the previous several months, but he had no other systemic symptoms such as fever, chills, night sweats, nausea, abdominal pain, or myalgias. He was not sexually active and had no urinary symptoms. He had no recent travel or exposure to animals. His medical history was significant for multiple sclerosis, which was well controlled with fingolimod (Gilenya). The patient immigrated from eastern Europe nearly 15 years earlier and was current on all recommended immunizations.

On physical examination, his vital signs were normal. He appeared cachectic. The painful nodules ranged from 1 cm to 8 cm in diameter and were located diffusely in the axillae, upper arms, thighs, chest, abdomen, groin, and buttocks (Figure 1). The lesions were blanchable, and some had small blood vessels visible around the periphery. The lesions showed no fluctuance, induration, crusting, or drainage. No palpable lymphadenopathy was noted.