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Answers on p 435.
A 46 year old man with a history of alcohol abuse was admitted with insidious onset, progressive left thigh swelling and abnormal skin lesions over an extensive part of his left thigh. There was no history of trauma. Examination revealed a jaundiced adult male, with hepatomegaly (liver edge felt 4 cm beneath the right costal margin; liver span 14 cm) and prominent skin lesions mainly involving the left thigh (fig 1). These lesions were not palpable. There was no mucosal or joint involvement. The left thigh was enlarged (girth about 1.4 times that of the right) and exquisitely tender, but there was no evidence of neurovascular compromise in the affected limb. The spleen was not palpable and there were no stigmata of chronic liver failure.
Laboratory test results (normal range in parentheses) were as follows: haemoglobin 92 g/l (140–180 g/l); leucocyte count 8.1 × 109/l (4–11 × 109/l); platelet count 87 × 109/l (130–400 × 109/l); mean corpuscular volume 102.3 fl (86–98 fl); red cell distribution width 15.2% (13%–15%); reticulocyte count 3.63% (0.2%–2%); total bilirubin 241 μmol/l (5.1–17 μmol/l); direct bilirubin 132 μmol/l (1.7–5.1 μmol/l ); serum albumin 25 g/l (33–55); aspartate aminotransferase 197 U/l (0–35 U/l); alanine aminotransferase 32 U/l (0–35 U/l); alkaline phosphatase 221 IU/l (30–120 IU/l); γ-glutamyl transpeptidase 107 IU/l (8–51 IU/l); international normalised ratio (INR) 1.33 (0.7–1.1); and activated partial thromboplastin time 36.2 sec (control 33.4 sec). Serum levels of vitamin B12, folate, ferritin, iron, transferrin, thyroid stimulating hormone, and α-fetoprotein were within normal limits. Hepatitis viral screen for A, B, and C viruses were negative. Ultrasonography and computed tomography of the abdomen were consistent with a diagnosis of steatohepatitis and gallstones. Magnetic resonance cholangiopancreatography revealed cholelithiasis, a dilated common bile duct (9 mm) without stones and a normal pancreatic duct. Arterial and venous Doppler studies of lower extremities excluded arterial insufficiency and deep venous thrombosis. Radiography of the left thigh did not reveal long bone fracture. A non-contrast computed tomogram (fig 2) showed a grossly enlarged left thigh with areas of increased attenuation in between, and within muscle groups, most prominent in the posteromedial aspect (fig 2, white arrow). This was thought to represent an extensive soft tissue haematoma.
How would you describe these skin lesions? What is the differential diagnoses?
What is the most likely cause of this patient’s skin lesions and thigh abnormality? What features of the skin lesion (fig 1, inset) suggests this diagnosis? How will you confirm the diagnosis?
How is this condition treated?