Verrucous nodules on distal limbs

Abstract

A 70-year-old man (Fig. 1) presented for consultation because of numerous verrucous lesions that appeared 5 years prior as small papules, which progressively grew in size and in number. He complained of on-and-off pain associated with these lesions and had difficulty wearing his usual shoes and walking. The lesions on his hand interfered with the performance of daily duties, such as buttoning his shirt, and caused him social embarrassment. The nodules were initially diagnosed as common warts, but treatment with several types of topicals was unsuccessful. His comorbidities were IgA monoclonal gammopathy of undetermined significance (MGUS), essential hypertension treated with candesartan, type IIb hyperlipidemia treated with atorvastatin, and atrial fibrillation treated with acenocoumarol. Physical examination was otherwise normal including neurological examination. Laboratory tests showed negative hepatitis B and HIV serology, mild elevation of erythrocyte sedimentation rate and C reactive protein levels, and severe anemia with microcytosis and hypochromia; his serum M-protein level was < 3 g/dl, and bone marrow biopsy showed <10% plasma cells. There was no evidence of multiple myeloma or Waldenstrom’s macroglobulinemia by laboratory or imaging tests and no hypercalcemia or renal function impairment. Nerve conduction studies were normal. Angiodysplasia of the gastrointestinal tract was found to be a cause of blood loss in this patient, and his iron deficiency was treated. Histology: A biopsy of one of the lesions on his left hand was performed and showed hyperkeratosis, acanthosis, and papillomatosis (Fig. 2) overlying a hypercellular dermis with prominent fibroplasia in the form of interweaving bundles of collagen. The blood vessel walls were infiltrated by inflammatory cells, particularly neutrophils, nuclear dust, and mononuclear cells. Figure 1 Hyperkeratotic coalescent verrucous nodules on extremities