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28-year-old man presented to his dentist with an unresolving left mouth ulcer associated with tenderness over his left jaw. He was a chronic smoker of 10 pack-years, and over the preceding 4 years, the ulcer had regressed when he stopped smoking and relapsed when he restarted. There was also an associated skin lesion over his left shoulder that similarly waxed and waned with his smoking habit. The rest of his systemic review was unremarkable; specifi cally, he denied any cough or dyspnea. He had no signifi cant medical history of note. Clinical examination was remarkable for a 3 cm 3 6 cm left buccal ulceration and a 6 cm 3 4 cm left shoulder papular rash, which was tender on palpation. He was not clubbed, and there was no palpable lymphadenopathy or organomegaly. Auscultation of his lung fi elds was clear, and there were no neurologic abnormalities on gross examination. A CBC count, including WBC differential, was normal. Serum electrolytes, creatinine, liver function, calcium, and phosphate were all within normal limits. Pulmonary function tests showed a restrictive pattern on spirometry with an FEV 1 of 2.74 L (71% predicted), an FVC of 3.29 L (68% predicted), and an FEV 1 � FVC ratio of 83%. There was no signifi cant bronchodilator response. However, residual volume was normal, and total lung capacity was preserved. Diffusion coeffi cient was also normal. CT scan of his postnasal space, thorax, and abdomen was performed. CT scan of his thorax showed the