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Quiz Case

Diffuse Skin Thickening and Linear Papules in a 59-Year-Old Woman

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Figure 1.

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A 59-year-old woman presented with a 4-month history of diffuse skin thickening with overlying linear papules. She reported associated dyspnea, muscle weakness, fatigue, decreased acral range of motion, and decreased oral aperture. She had restrictive lung disease of unknown origin. Examination showed numerous 1- to 3-mm waxy, flesh-colored papules arranged in a linear array on the postauricular scalp, flexural neck (Figure 1), antecubital fossae, and extensor knees. The surrounding skin was shiny and indurated. A complete blood cell count and findings from serum creatinine and thyroid stimulating hormone tests were within normal limits. Antinuclear, antiscleroderma-70, and anticentromere antibodies were absent. Initial serum protein electrophoresis revealed restricted mobility in a poorly defined band of γ-globulins. A second serum protein electrophoresis showed 2 monoclonal M spikes. Two IgG monoclonal proteins, λ light chains and κ light chains, were detected on immunofixation electrophoresis. Punch biopsy specimens were obtained from the thigh and back for routine histopathologic analysis (Figure 2) and colloidal iron staining (Figure 3).

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For comments or suggestions about the Archives Clinical Challenge, please contact us at jama-comments@jama-archives.org.
Ashish Bhatia, MD, Web Editor, Archives of Dermatology.