Multiple Follicular Keratotic Papules in a Patient With a Distal Limb Polyneuropathy: Challenge

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A 39-year-old man with a medical history of chronic back pain, gastritis, and alcohol abuse presented to the emergency department for 1 month of worsening back pain. He reported new radiation of lancinating pain to the bilateral lower extremities associated with numbness and tingling and lower extremity weakness along with difficulty ambulating. The patient's wife also reported that the patient seemed confused and had “not been acting like himself.” Additionally, she reported the development of 2 different skin eruptions within the last month. Of note, the patient had primarily subsisted on alcohol for the previous 3 months with little impulse to eat.
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).
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