Pulse granulomas are rare foreign body reactions to vegetable material characterized by hyaline rings or starch granules. Pulse granulomas have mainly been reported in association with lung aspirations, the oral cavity with a history of oral procedures and less frequently in intestinal fistulae, colonic diverticulae or stomach ulcers. Only one case involving the skin has been reported in a patient with jejunocutaneous and ileocutaneous fistulae. We report the second cutaneous pulse granuloma in a patient with a rectocutaneous fistula.

An 84-year-old male presented with two large masses on the left leg and a large mass on the right leg. The patient reported that the two masses on the left leg had been there for approximately 2 years. He did not report any significant symptoms related to the masses on lower extremities other than dislike for the size and concern for "impending rupture."On examination of the left leg, the patient had two large, nonpulsatile masses on the medial aspect (A). Masses were soft, nontender, and had no Doppler signal. His pulse examination demonstrated a left femoral pulse with no distal pulses. There were biphasic Doppler signals in the left dorsal pedal and posterior tibial positions with an ankle-brachial index of 0.8. The right leg had a large, pulsatile mass on the medial thigh. There were palpable femoral and popliteal pulses with an anklebrachial index of 0.9.Computed tomography angiogram of the left lower extremity showed a multilobulated mass (21.7 ϫ 18 ϫ 40 cm) extending from mid-thigh to mid-calf, consistent with a contained rupture of a giant popliteal artery aneurysm with thrombosis. On the right, there was a giant popliteal artery aneurysm (8.5 ϫ 9.7 ϫ 16.6 cm) with significant intraluminal thrombus with patent outflow vessels (B). Angiogram of the left leg showed reconstitution of the distal popliteal artery and two-vessel runoff to the left foot (C).Exploration of the left leg was performed, and both masses were consistent with old hematomas within a pseudocapsule (D). The masses were evacuated, and revascularization was not necessary due to adequate collateral blood flow. Seven days after his initial surgery, he was returned to the operating room for ligation and bypass of his right popliteal artery aneurysm with nonreversed greater saphenous vein.Popliteal artery aneurysms are defined as dilation of the popliteal artery over 2 cm in diameter. 1 Popliteal artery aneurysms are most commonly symptomatic secondary to a thromboembolic event, acute rupture, or compression of adjacent structures. 2 This case is unusual in that the patient was relatively asymptomatic upon presentation and did not require revascularization of the left leg. Only one similar case has been reported in the literature. 1

Appendiceal malakoplakia masquerading as a cecal mass is uniquely rare. The presence of an infiltrate of granular eosinophilic macrophages containing Michaelis–Gutmann bodies on histopathology is pathognomonic of malakoplakia. Cutaneous, gastrointestinal and most commonly urogenital malakoplakia is reported in association with an immunocompromised state, infectious, inflammatory and neoplastic processes. Presentation varies from microscopic disease to plaques, nodules, polypoid lesions and small masses. However, a cecal mass postea proven appendiceal malakoplakia deserves special attention. We could not find similar case reports in the English literature. The pathogenesis of malakoplakia is poorly understood, and it is unclear if it is a harbinger of malignancy, a precursor lesion or an inflammatory marker. In the setting of a dominant appendiceal mass, post-treatment endoscopic and tumor marker surveillance is paramount but, however, undefined in contemporary literature.

A 38‐year‐old woman presented with nodules on the face, scalp, ears, hands and elbows. She also developed fevers, chills, fatigue, weakness, myalgia, joint pain, nausea and weight loss of 40 pounds in eight months. Histology revealed large histiocytes with smooth eosinophilic ground glass cytoplasm, consistent with multicentric reticulohistiocytosis. She was treated with methotrexate 25 mg IM per week and prednisone 10 mg PO QD, with relief of her symptoms and improvement in her skin. Multicentric reticulohistiocytosis is a rare histiocytic systemic disease, with facial and hand skin nodules and symmetric arthritis. Pathognomonic signs include “coral beads” and vermicular erythematous papules bordering nostrils. The histologic hallmark for this disease is a nodular infiltrate of histiocytic cells, including multinucleated giant cells containing an eosinophilic, ground glass cytoplasm. Immunohistiochemistry is positive for CD68 and CD3, and negative for B cell markers as well as Langerhans cell markers. Approximately twenty percent of patients with multicentric reticulohistiocytosis have concurrent malignancy, but there is no one predominant type. The disease usually waxes and wanes for many years, with 30% of patients developing arthritis mutilans. It often regresses approximately seven years after its first appearance.

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