A 40-Year-Old Man With a Nodular Lung Disease and Skin Rash Saadah Alrajab, MD, MPH, Keith Payne, MD, John Areno, MD, FCCP, Robert Holladay, MD, FCCP, Toby Smith, MD, Songlin Zhang, MD  CHEST  Volume 141, Issue 6, Pages 1611-1617 (June 2012) DOI: 10.1378/chest.11-1100 Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 1 The skin lesion consisted of raised, hyperpigmented, nontender infiltrated nodules and plaques with some overlying scales (marks of the recent skin biopsies are present). The patient provided written consent for the use of this photograph. CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 2 A, CXR on presentation reveals right lower lung field opacity. B, Contrast-enhanced CT scan of the chest; lung and mediastinal windows on presentation reveal a cluster of three small subpleural nodules on the lateral aspect of the right middle lobe. A smaller left lower lobe and right lower lobe subpleural nodules were also identified. No evidence of mediastinal adenopathy or pleural effusions was identified on this CT scan. CXR = chest radiograph. CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 3 FDG PET/CT scan reveals intense FDG uptake in the right middle lobe pulmonary nodules on initial presentation. FDG = (18)F-fluorodeoxyglucose. CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 4 A, B, Lung biopsies, obtained via a percutaneous CT imaging-guided approach, showed nonspecific fibrotic tissue with dense lymphoplasmacytic infiltrate and (B) possible perivascular distribution. (hematoxylin and eosin, original magnification ×200). CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 5 Representative cut from repeat CT scan of chest without contrast obtained just before initiation of treatment revealed development of new small subpleural nodules in the right lung field and multiple tiny centrilubar nodules in the right lung as well as left lung fields. CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 6 Skin biopsy specimen obtained from left leg skin rash revealed: A, superficial and deep dense lymphoplasmacytic infiltrate, focal nonnecrotizing granulomas (hematoxylin and eosin, original magnification ×40); B, plasma-rich and prominent perivascular infiltrate (hematoxylin and eosin, original magnification ×200). CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 7 A, Representative cut from CT scan of the chest, 4 months after completion of treatment reveals near-complete resolution of the lung nodules. B, CXR 6 months after treatment reveals clear lung fields. See Figure 2 legend for expansion of abbreviation. CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions

Figure 8 Skin rash 6 weeks after completion treatment with benzathine penicillin, only residual chronic postinflammatory pigmentation is noted. The patient provided written consent for the use of this photograph. CHEST 2012 141, 1611-1617DOI: (10.1378/chest.11-1100) Copyright © 2012 The American College of Chest Physicians Terms and Conditions