Abstract:

A 43-year-old African American female was diagnosed with pulmonary sarcoidosis after 9 months of dry cough and lung biopsy showing non-caseating granulomas. She began treatment with systemic steroids. She subsequently developed a rapid-growing verrucous tumor on the nasal ala and verrucous plaque on her left thigh. Outside shave biopsies of these lesions were interpreted as well-differentiated squamous cell carcinomas. She was admitted from pulmonology clinic due to concerns of airway compromise from her rapidly-proliferative nasal squamous cell carcinoma. Computed tomography of the neck revealed matted cervical lymphadenopathy. Otolaryngology was consulted and recommended excision of the nasal plaque via rhinectomy. Dermatology was consulted for further evaluation of her skin lesions. Examination revealed a verrucous, hyperpigmented, pink and yellow scaly tumor on the nasal sidewall, dorsum, tip, and ala. Hyperpigmented and verrucous plaques on the thighs and an ill-defined erythematous, tender plaque made of agminated, discrete papules, nodules, and few pustules on the right upper back were also noted. Skin biopsy from the nose and back revealed yeast forms within the dermis with associated necrotizing and suppurative granulomata and pseudoepitheliomatous hyperplasia. The yeast forms were most consistent with blastomycosis. Fungal tissue culture grew blastomyces dermatitidis. The patient began amphotericin therapy inpatient with improvement in her dyspnea and erythema/oozing from skin lesions. Investigation of her pulmonary diagnosis is ongoing, but currently thought to be due to blastomycosis as well and not sarcoidosis. This case demonstrates a rare but perilous diagnostic pitfall of pseudoepitheliomatous hyperplasia associated with blastomycosis misdiagnosed as squamous cell carcinoma.

Financial Disclosure:
No current or relevant financial relationships exist.

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Meera Brahmbhatt, MD