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Painful leg mass

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The moist purple exophytic lesion on the patient’s lower leg prompted him to seek care. Unfortunately, it was just the tip of the iceberg.


 

References

A 61-year-old Caucasian man sought care at our emergency department for a painful mass on his right leg that had appeared and progressively enlarged over the past 3 weeks. The patient denied trauma prior to the appearance of the mass, but did note extensive varicosities spanning from the right groin to the right foot a few weeks before the lesion appeared.

He also indicated that he’d had progressive dyspnea and intermittent chest pain for the past 4 months, a 30-lb weight loss in the past 6 months without change in appetite or diet, a depressed mood, and generalized weakness.

The patient’s past medical history was notable for hypertension and coronary artery disease. He reported a 30 pack-year smoking history, but had quit 12 years earlier. He denied alcohol use, although there was a family history of alcoholism and chronic obstructive pulmonary disease.

Physical examination revealed a frail, pale, unkempt man. His vital signs were normal except for mild tachycardia. Additional findings included:

  • nonicteric, pale palpebral conjunctivae
  • a 3/6 nonradiating holosystolic murmur heard along the left upper sternal border
  • a large friable 3.5-cm pedunculated mass on a 2-cm stalk located on right lower leg (FIGURE 1); the lesion was moist, purple, and exophytic
  • bilateral enlargement of the inguinal lymph nodes.

Lab work revealed microcytic anemia with a hemoglobin count of 5.8 g/dL and mild hyponatremia. The patient’s liver and renal function were normal. Urinalysis showed 3 red blood cells (RBCs) and a chest x-ray revealed bilateral hilar lymphadenopathy.

FIGURE 1
Exophytic mass on right lower leg

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