Painful Nodules on the Thighs
Abstract
Case Presentation A 23-year-old woman consulted for the gradual appearance of painful lesions on the external aspect of the thighs. The lesions had first appeared 5 weeks earlier. The patient reported similar flare-ups over 3 consecutive years; these appeared during the coldest months of the year and resolved without scarring as the seasonal temperature increased. No other manifestations were observed. The patient was a horseback rider and rode and cared for horses on a daily basis. Physical Examination The examination revealed erythematous-violaceous lesions that were painful to the touch and tended to coalesce and form plaques on the outer part of the upper thigh (bothlegs) (Fig. 1). Erythematous-violaceous reticulated macules with a vascular appearance were observed on the rest of the thigh. The local temperature was lower in the affectedareas. ... Conejero, R.; Rivera-Rodríguez, Á.; Ara, M.
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ACTAS
De mo-Sifiliog áficas
xxx
(xxxx)
xxx---xxx
CASE
FOR
DIAGNOSIS
Pain ul
Nodules
on
he
Thighs夽
Nódulos
dolo osos
en
muslos
Case
P esen a ion
A
23-yea -old
woman
consul ed
o
he
g adual
appea ance
o
pain ul
lesions
on
he
ex e nal
aspec
o
he
highs.
The
lesions
had
fi s
appea ed
5
weeks
ea lie .
The
pa ien
epo ed
simila
fla e-ups
o e
3
consecu i e
yea s;
hese
appea ed
du ing
he
coldes
mon hs
o
he
yea
and
esol ed
wi hou
sca ing
as
he
seasonal
empe a u e
inc eased.
No
o he
mani es a ions
we e
obse ed.
The
pa ien
was
a
ho seback
ide
and
ode
and
ca ed
o
ho ses
on
a
daily
basis.
Physical
Examina ion
The
examina ion
e ealed
e y hema ous- iolaceous
lesions
ha
we e
pain ul
o
he
ouch
and
ended
o
coalesce
and
o m
plaques
on
he
ou e
pa
o
he
uppe
high
(bo h
legs)
(Fig.
1).
E y hema ous- iolaceous
e icula ed
macules
wi h
a
ascula
appea ance
we e
obse ed
on
he
es
o
he
high.
The
local
empe a u e
was
lowe
in
he
a ec ed
a eas.
Figu e
1
Clinical
image.
夽Please
ci e
his
a icle
as:
Coneje o
R,
Ri e a-Rod íguez
Á,
A a
M.
Nódulos
dolo osos
en
muslos.
Ac as
De mosifiliog .
2020.
h ps://doi.o g/10.1016/j.ad.2019.05.020
Figu e
2
His ology.
A.
Hema oxylin-eosin,
o iginal
magnifica-
ion,
×10.
B
and
C.
Hema oxylin-eosin,
o iginal
magnifica ion,
×40.
His opa hology
The
his opa hology
wo kup
(Fig.
2A)
e ealed
a
pe i ascu-
la
and
pe iadnexal
de mal
lymphocy ic
infil a e
benea h
a
no mal
epide mis
(Fig.
2C),
as
well
as
enuli is
in
he
deep
e icula
de mis
and
hypode mis
(Fig.
2B).
No
signs
o
pan-
niculi is
we e
obse ed.
Alcian-blue
s aining
did
no
e eal
mucin
deposi s.
Addi ional
Tes s
The
esul s
o
he
labo a o y
wo k-up
we e
no mal
(nega-
i e
o
au oimmuni y,
cold
agglu inins,
c yoglobulins,
and
se ology).
Capilla oscopy
pe o med
on
he
hands
e ealed
no mal
findings,
as
did
Dopple
ul asound
o
he
lowe
limbs.
1578-2190/©
2020
AEDV.
Published
by
Else ie
Espa˜
na,
S.L.U.
This
is
an
open
access
a icle
unde
he
CC
BY-NC-ND
license
(h p://
c ea i ecommons.o g/licenses/by-nc-nd/4.0/).
ADENGL-2503;
No.
o
Pages
2
ARTICLE IN PRESS
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R.
Coneje o,
Á.
Ri e a-Rod íguez
and
M.
A a
Wha
is
You
Diagnosis?
Diagnosis
Cold-associa ed
pe niosis
o
he
highs
(CAPT).
Cou se
and
T ea men
The
pa ien
was
ecommended
o
wea
loose
clo hing
and
p esc ibed
medium-po ency
opical
co icos e oids.
The
lesions
had
imp o ed
a
he
1-mon h
check-up.
Commen
CAPT
is
he
e m
p oposed
in
2016
by
Fe a a
and
Ce oni1
o
desc ibe
a
condi ion
o
which
no
consensus
had
been
eached
and
ha
had
been
epo ed
wi h
a ious
names:
eques ian
panniculi is,
eques ian- ype
pe niosis,
o
eques ian- ype
chilblains.
Diagnosis
is
based
on
p e ious
exposu e
o
cold,
cu aneous
lesions
on
he
side
o
he
highs,
and
a
compa ible
his o y.
The
usual
clinical
pic u e
o
CAPT
does
no
di e
signi-
fican ly
om
ha
o iginally
desc ibed
in
1980
by
Beacham
e
al.2unde
he
name
o
eques ian
cold
panniculi is.
I
is
cha ac e ized
by
he
p esence
o
infil a ed
e y hema ous-
iolaceous
plaques
ha
may
be
p u i ic
o
pain ul.
The
plaques
a e
ound
mainly
on
he
ou e
pa
o
he
uppe
high
and
a e
no
accompanied
by
o he
abno mali ies.
The
e m
eques ian
was
eplaced
by
cold-associa ed.
O he
causes
ha e
been
iden ified,
o
example,
iding
a
bicycle,
occupa ional
exposu e
o
humid
en i onmen s,
oboganning,3wea ing
jeans
wi h
a
low
wais band,4and
applica ion
o
icepacks.5
The
e m
pe niosis
is
now
p e e ed
o
panniculi is
because
signs
o
panniculi is
we e
no
obse ed
in
many
o
he
cases
analyzed.
The
mos
common
finding
is
a
pe i ascula
and
pe iadnexal
lymphocy ic
infil a e
in
he
supe ficial
and
deep
de mis.
O he
findings
include
mucin
deposi s
in
he
de mis
and
inflamma ion
o
small-
and
medium-calibe
enules.
Some
cases
also
p esen
lympho-
cy ic
lobula
panniculi is,
which
is
p obably
an
ad anced
s age
o
deep
enuli is.
His ology
makes
i
possible
o
di -
e en ia e
he
condi ion
om
o he
condi ions
in
which
cold
leads
o
nec osis
o
hypode mal
a ,
such
as
Hax hausen
disease
o
panniculi is
caused
by
sucking
ice
c eam;
he
e m
cold-induced
panniculi is
should
be
ese ed
o
hese
condi ions.1,6 Fu he mo e,
cases
o
cold-induced
de ma o-
sis
ha e
been
epo ed
in
ho seback
ide s
o
pe sons
who
ha e
applied
cold
locally
in
o de
o
ea
low
back
pain.
This
can
ake
he
o m
o
panniculi is
and
chilblains
(pe niosis),
which,
in
his ologic
e ms,
esemble
lupus.7
The
ou e
pa
o
he
uppe
high
is
he
mos
common
loca ion,
o
se e al
easons.
The
a ea
is
mo e
exposed
o
cold,
hus
leading
o
asocons ic ion
and
inc eased
blood
iscosi y.
In
addi ion,
i
is
exposed
o
igh
clo hes
ha
place
con inuous
p essu e
on
he
a ea
and
educe
blood
flow
in
he
subcu aneous
a .
Mo eo e ,
he
a ea
is
cha ac e ized
by
abundan
adipose
issue,
which
isola es
blood
essels
and
makes
hem
mo e
suscep ible
o
he
e ec s
o
cold.8
T ea men
is
based
on
ecommending
loose
clo hing.
Top-
ical
co icos e oids
can
also
be
applied.
Vasodila o s
a e
no
use ul.9The
condi ion
usually
esol es
wi hou
sca ing
a e
a
ew
weeks.
Conflic s
o
In e es
The
au ho s
decla e
ha
hey
ha e
no
conflic s
o
in e es .
Re e ences
1.
Fe a a
G,
Ce oni
L.
Cold-Associa ed
Pe niosis
o
he
Thighs
(‘‘Eques ian-Type’’
Chilblain):
A
Reapp aisal
Based
on
a
Clini-
copa hologic
and
Immunohis ochemical
S udy
o
6
Cases.
Am
J
De ma opa hol.
2016;38:726---31.
2.
Beacham
BE,
Coope
PH,
Buchanan
CS,
Wea y
PE.
Eques ian
cold
panniculi is
in
women.
A ch
De ma ol.
1980;116:1025---7.
3.
Long
CC,
Hol
PJ.
Toboggane s
highs.
Clin
Exp
De ma ol.
1992;17:466---7.
4.
Weismann
K,
La sen
FG.
Pe nio
o
he
hips
in
young
gi ls
wea ing
igh -fi ing
jeans
wi h
a
low
wais band.
Ac a
De m
Vene eol.
2006;86:558---9.
5.
Wes
SE,
McCalmon
TH,
No h
JP.
Ice-pack
de ma osis:
a
cold-
induced
de ma i is
wi h
simila i ies
o
cold
panniculi is
and
pe niosis
ha
his opa hologically
esembles
lupus.
JAMA
De ma-
ol.
2013;149:1314---8.
6.
S ewa
CL,
Adle
DJ,
Jacobson
A,
B od
BA,
Shinoha a
MM,
Seyko a
JT,
e
al.
Eques ian
pe niosis:
a
epo
o
2
cases
and
a
e iew
o
he
li e a u e.
Am
J
De ma opa hol.
2013;35:237---40.
7.
Ka kouche
R,
Be nigaud
C,
Fon ugne
J,
Zehou
O,
Bellaud
G,
N’Diaye
M,
e
al.
Cold-associa ed
pe niosis
o
he
highs
his opa hologically
mimicking
lupus.
Six
obse a ions.
J
Eu
Acad
De ma ol
Vene eol.
2017;31:1029---32.
8.
De
Sil a
BD,
McLa en
K,
Dohe y
VR.
Eques ian
pe niosis
asso-
cia ed
wi h
cold
agglu inins:
a
no el
finding.
Clin
Exp
De ma ol.
2000;25:285---8.
9.
Kluge
N,
Ma y
L,
Bou seau-Que ie
C,
Blum
M,
Camus
M.
Pe nio-
sis/cold
panniculi is
in
F ench
eques ians:
ou
cases.
In
J
De ma ol.
2016;55:e618---20.
R.
Coneje o,a,∗Á.
Ri e a-Rod íguez,bM.
A ac
aDepa amen o
de
De ma ología,
Hospi al
Royo
Villano a,
Za agoza,
Spain
bDepa amen o
de
De ma ología
del
Hospi al
de
Alca˜
niz,
Te uel,
Spain
cSe icio
de
De ma ología,
Hospi al
Clínico
Uni e si a io
Lozano
Blesa,
Za agoza,
Spain
∗Co esponding
au ho .
E-mail
add ess:
[email p o ec ed]
(R.
Coneje o).
22
Feb ua y
2019
23
May
2019
2