Violaceous Nodules on the Leg in a Patient with HIV

Abstract

A 67-year-old man with long-standing hepatitis B virus and HIV managed with chronic antiretroviral therapy presented to an urgent care facility with worsening erythema and edema of the legs of 2 weeks' duration. He was prescribed a 7-day course of cephalexin for presumed cellulitis. Two months later, he developed nodules on the lower extremities. He was seen by podiatry and prescribed a course of amoxicillin-clavulanic acid for presumed infection. Despite 2 courses of antibiotics, his symptoms progressed. The nodules expanded in number and some developed ulceration. Three months into his clinical course, he presented to our dermatology clinic. Physical examination revealed two 2-to 3-cm, violaceous, exophytic, tender nodules. He reported tactile allodynia of the lower extremities and denied fever, chills, night sweats, or weight loss. He also denied exposure to infectious or chemical agents and reported no recent travel. The patient was chronically taking lisinopril/hydrochlorothiazide, escitalopram, elvitegravir/cobicistat/emtricitabine/tenofovir alafenamide, bupropion, and aspirin with no recent changes. A complete hematologic and biochemical survey largely was unremarkable. His HIV viral load was undetectable with a CD4 count greater than 400/mm 3 (reference range, 490-1436/mm 3 ). Lactate dehydrogenase was elevated at 568 IU/L (reference range, 135-225 IU/L). The lower leg lesions were biopsied for confirmatory diagnosis. WHAT'S YOUR DIAGNOSIS?a. bacillary angiomatosis b. Kaposi sarcoma c. lymphomatoid papulosis d. plasmablastic lymphoma e. plasmablastic myeloma Drs.