A 14-Year-Old Boy With Nodules on His Feet

A 14-year-old previously healthy boy was referred to the pediatric infectious disease clinic for evaluation of painful nodules, which had been present for 2 weeks, on both soles of his feet. The nodules were first noted 2 weeks after returning to the United States from a 1-month family vacation to visit relatives in his native Guyana, South America. The foot nodules were unimproved after application of topical Neosporin and a 1-week course of oral trimethoprimsulfamethoxazole prescribed by his primary care physician. The nodules were nonpurulent but expressed serosanguinous fluid. Neither he nor other family members had developed skin lesions during the trip itself. The patient denied systemic symptoms, including fever, rash, headache, respiratory, or joint complaints. He had no significant past medical history or drug allergies. The patient denied swimming in fresh or sea water, insect bites, or animal contact, and he denied sexual activity; however, he did walk with sandals in sandy soil. On physical examination, his vital signs were within normal limits. The examination was notable only for nodules to the soles of his feet bilaterally (as shown in Figure 1). He had approximately 20 firm, nodules (1 × 2 cm) on his right foot and 9 discrete (1 × 2 cm) nodules on his left. His physical examination was otherwise unremarkable. After dermatology consultation, an excisional skin biopsy was performed with microscopic examination of the biopsy specimens, which confirmed the visual diagnosis.