MED-1. "Doctor, I have these bumps": the mystery of multiple ulcerative nodules.

A 41-year-old female presented for evaluation of several nontender, freely mobile subcutaneous masses of varying sizes scattered across her buttocks, thighs, abdomen, and back. The masses evolved into painful ulcers draining serosanguinous fluid. Bacterial cultures of this fluid were negative and biopsy findings were initially nonspecific. Meanwhile, the patient developed right ear pain and hearing loss, followed by right-sided Bell's palsy, intermittent left eye blindness, and painful oral ulcers. Computed tomography of the sinuses demonstrated nonspecific opacification of the right mastoid air cells, leading to a diagnosis of otomastoiditis. Biopsy of the sinus mucosa was unremarkable. The patient underwent myringotomy and treatment with multiple antibiotics for presumed infection. She was subsequently transferred to our medical center for further evaluation. Laboratory evaluation revealed leukocytosis, thrombocytosis, anemia, and elevated erythrocyte sedimentation rate. Renal function was within normal limits, while c-ANCA was markedly elevated at 1:4096. Chest computed tomography performed after the patient developed shortness of breath demonstrated a cavitary lesion of the left upper lobe without infiltrate. Dilated funduscopic examination revealed bilateral optic neuritis. An excisional biopsy of a virgin subcutaneous nodule was performed, showing small and medium vessel vasculitis with granulomatous features, consistent with Wegener's granulomatosis. The patient began treatment with cyclophosphamide and prednisone, experiencing a subjective improvement in malaise, skin findings, and visual deficits prior to discharge. This case demonstrates an unusual presentation of Wegener's granulomatosis, typically characterized by the recognized triad of upper and lower respiratory symptoms, such as epistaxis and dyspnea, and renal disease manifesting as proteinuria, hematuria, or red blood cell casts. The key diagnostic features of Wegener's are discussed, specifically highlighting findings of this case.

Anna L. Sobol, MD, and Michael B. Phillips, MD. Department of Internal Medicine, Mayo Clinic, Jacksonville, FL.