PMC6010973_01
Lateral left leg and medial right leg with several cutaneous nodules (A). Medial aspect of left leg with nodule and crust overlying sinus tract (B-C). Right fifth metacarpal with overlying soft tissue edema and crust over prior drainage tract (D-E).
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However, skin nodules were noted on his elbows, left lower extremity (Fig. 1A-C), and right hand (Fig. 1D-E).
Axial computed tomography (CT) image showing fluid pocket in left leg (A). Radiograph of right hand showing cortical loss and sclerotic changes in right fifth metacarpal (B). Axial CT image of metacarpals showing destruction of the right fifth metacarpal, which suggests osteomyelitis (C).
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CT images of the left lower extremity showed a fluid collection along the posteromedial aspect of the left calf (Fig. 2A). CT images of the right upper extremity showed evidence of chronic destruction of the right 5th metacarpal bone with an associated 2-cm soft tissue mass (Fig. 2C).
Right hand tenosynovium biopsy showing necrotizing granulomatous inflammation with extensive necrosis (magnification 20X) (A). Right fifth finger amputation revealed necrotizing granulomatous osteomyelitis with extensive necrosis. There are extensive areas of necrosis (pink acellular material) intermixed with areas showing granulomatous inflammation with well-formed granulomas composed of epithelioid histiocytes and multinucleated giant cells (magnification 20X) (B).
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A biopsy of the right extensor digitorum profundus synovium demonstrated necrotizing granulomatous inflammation with extensive necrosis (Fig. 3A). Hematoxylin and eosin (H&E) staining of the right fifth finger amputation showed necrotizing granulomatous osteomyelitis with extensive necrosis (Fig. 3B).