Multiple Follicular Keratotic Papules in a Patient With a Distal Limb Polyneuropathy: Challenge
Physical examination was remarkable for a series of follicularly based keratotic papules with subtle perifollicular purpura located on his forearms, elbows, legs, and forehead—sparing the trunk (Figs. 1A, B). He also had scaly, well-defined hyperpigmented plaques in a polycyclic configuration to the posterior neck, buttocks, and scrotum (Fig. 2). He had generalized cutaneous xerosis. His left oral commissure showed upper and lower lip thin erosions. Neurologic examination demonstrated bilateral horizontal and vertical nystagmus, decreased bilateral lower extremity strength, and diminished bilateral lower extremity sensation to pinprick and vibration stimuli with lower extremity hyperreflexia along with clonus at the right ankle. On admission, laboratory results showed a macrocytic anemia with a hemoglobin of 11 g/dL (reference range 13.5–17.5 g/dL) and hypoalbuminemia at 2.7 g/dL (reference range 3.5–5.5 g/dL) whereas renal function and liver transaminases were within normal limits. Two punch biopsies were performed to lesions on the left forearm and the neck (Figs. 3A, B).