Diagnostic Dilemma: Dermatology

A 49-year-old Caucasian man presented with progressing erythematous plaques on the face and neck in December 2007. He was treated with topical steroids, presumably for dermatitis, without improvement. Physical examination revealed a well-appearing man in no acute distress. There were erythematous to yellowish waxy plaques involving the face and neck area (see Figures 1A and 1B).



The patient denied pruritus or constitutional symptoms. There was no lymphadenopathy, and liver and spleen were not enlarged. His vital signs were normal. The remainder of the physical examination was unremarkable.

Laboratory evaluation showed a normal complete blood cell count and differential, comprehensive metabolic panel, and LDH. IgM levels were elevated 677 mg/dL with evidence of a small amount of IgM kappa-restricted immunoglobulins. Serum and urine protein electrophoresis and erythrocyte sedimentation rate studies revealed normal findings. A punch biopsy was performed (see Figures 2A and 2B).

1) The photographs reveal findings noted at the time of a diagnostic and therapeutic procedure. What is your diagnosis?

a) Sarcoidosis
b) Granuloma faciale
c) Cutaneous plasmacytoma
d) Systemic monoclonal gammopathy-associated amyloidosis

Answer on next page.