A 44-year-old man presented with a week history of tender, erythematous maculopapules on his right foot. He had noted three episodes of acral maculopapules in the previous 6 months, mainly on his right hand including the palm, which had resolved within 2-3 weeks without treatment. The most recent cutaneous lesions had appeared 1 month ago and the lesions had resolved spontaneously within 2 weeks. Additionally, the patient had a 4-month history of intermittent episodes of myalgia in the right upper and lower extremities.
Fig. 1 Tender, blanching, erythematous maculopapules on the side and sole of the right foot.
Physical examination revealed multiple tender, violaceous, erythematous maculopapules on the sole and side of the right foot (Fig. 1). Routine laboratory analyses, serology for treponematosis (TPHA, VDRL), and muscle enzymes were within normal limits. He denied any history of fever, chills, arthralgias, weight loss, dyspnea, syncope, palpitation, or cardiac symptoms. A skin biopsy was taken from a tender papule on the sole. Histopathologic examination revealed no abnormality in the epidermis. But in the dermis, there were vessels occluded by hypocellular myxoid material (Fig. 2A). The myxoid intravascular material reacted positively with alcian blue stain at PH 2.5 (Fig. 2B). Based upon these findings, embolization by cardiac myxoma was suspected and an echocardiogram was performed. It demonstrated a 4 x 3 cm-sized mobile mass in the left atrium.
Fig. 2. (A) Amorphous intravascular material occlud – ing the vessels in the dermis (H&E, x 100). (B) Myxoid intravascular deposit reacted positively with alcian blue stain at PH 2.5 (Alcian blue,x 100).
Open-heart surgery was performed for mass excision (Fig. 3). Pathologic examination confirmed a diagnosis of myxoma. Following surgery, the tender erythematous maculopapules and myalgia disappeared rapidly.
Fig. 3. The cardiac myxoma was removed