A solitary red nodule on the wrist: bacillary angiomatosis in a patient with lymphoplasmacytic lymphoma
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A 54-year-old male with well-controlled human immunodeficiency virus (HIV) presented with fevers and a red nodule on the wrist. Two weeks previous, he was scratched by his cat. His medical history included lymphoplasmacytic lymphoma (LPL) with Waldenstrom macroglobulinemia. A solitary 1.7cm red nodule was present on the right wrist (Figure 1). He was febrile to 103F. A complete blood count showed baseline anemia and thrombocytopenia. The complete metabolic panel was unremarkable. His CD4+ T-cell count was 466 cells/mm3 (reference 410-961 cells/mm3), and his HIV viral load was undetectable. Historically, the patient's CD4 nadir was 274 cells/mm3. The patient underwent shave removal of the visible nodule. Histopathologic examination of the nodule demonstrated diffuse dermal vascular proliferation (Figure 2). Gram, Gomori methenamine silver, acid-fast bacillus, and human herpesvirus-8 stains were negative. There was focal uptake within the dermis with Warthin-Starry stain (Figure 3). Tissue and blood cultures were negative. Polymerase chain reaction (PCR) from the tissue sample was positive for Bartonella henselae DNA, consistent with a diagnosis of bacillary angiomatosis (BA). The patient was started on a 3-month course of doxycycline. At his follow-up appointment one month later, he continued to be afebrile. The biopsy site healed with a circular scar without recurrence.
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