Skinternal Medicine: A Case Based Challenge

In a case presentation by Dr. Courtney Schott from the University of Louisville, a 75-year-old woman with a two-year history of skin plaques was discussed. Initially misdiagnosed as dermatofibromas, her lesions were biopsied, revealing a dermal infiltrate with multinucleate giant cells, suggesting granulomatous conditions. Diagnostic considerations included necrobiotic xanthogranuloma (NXG) and granuloma annulare, with the final diagnosis being NXG associated with smoldering multiple myeloma. Initial treatments involved intralesional triamcinolone, which showed minimal efficacy. Further investigation revealed a monoclonal IgG lambda light chain protein, and a subsequent bone marrow biopsy indicated a low level of atypical plasma cells. As her skin lesions progressed and her condition deteriorated, a multidisciplinary approach was taken, leading to the recommendation for treatment of the smoldering myeloma. The discussion emphasized the importance of recognizing the relationship between skin manifestations and underlying hematologic disorders, as well as the potential timing of associated conditions. Treatment options for NXG were explored, highlighting the varied responses to intravenous immunoglobulin, corticosteroids, and other agents. Ultimately, the patient was encouraged to initiate treatment for her smoldering myeloma, indicating a holistic approach to her complex condition.