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Multiple crateriform cutaneous nodules
Corresponding author: Dr. Keshavamurthy Vinay, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India. vinay.keshavmurthy@gmail.com
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Received: ,
Accepted: ,
How to cite this article: Gaikwad S, Sharma A, Chatterjee D, Vinay K. Multiple crateriform cutaneous nodules. Indian J Dermatol Venereol Leprol. 2026;92:407-9. doi: 10.25259/IJDVL_692_2025
A 54-year-old man with no known comorbidities presented with complains of episodic fever associated with chills and rigors. He also had multiple skin-coloured to reddish nodular lesions all over the body, severe radiating back pain, loss of appetite, excessive fatigue for the past month, and breathlessness (Modified Medical Research Council grade 4) for the last 15 days. The patient was a chronic smoker (30 pack years) and alcoholic. On mucocutaneous examination, there were multiple, well-defined skin-coloured to erythematous, firm, non-tender, succulent, papulonodular lesions ranging from 0.3×0.3 cm2 to 2×1.5 cm2, distributed over the head and neck, trunk, proximal extremities, and scrotum. A few nodules over the face and lips showed central umbilication covered with haemorrhagic crusts [Figure 1a]. Dermoscopy revealed polymorphic vessels, predominantly dilated tortuous and hairpin vessels arranged peripherally in a radiating fashion, with a central keratin plug and pinpoint haemorrhages [Figure 1b]. Laboratory investigations revealed transaminitis (aspartate transaminase (AST)/ alanine transaminase (ALT)-156/56U/L), elevated serum urea (53 mg/dL), and proteinuria (>300 mg/dL). High-resolution computed tomography (HRCT) chest revealed left lower lobe collapse with mild pleural effusion, conglomerated lymph nodes encasing the ascending aorta, left atrium, and upper pericardium, merging with enlarged mediastinal lymph nodes. Skin biopsy revealed atypical cells, oval to round in shape, having vesicular chromatin, conspicuous nucleolus, and a scant amount of cytoplasm, arranged in clusters, nests, and cords in the deep dermis and subcutaneous tissue [Figures 2a-b]. On immunohistochemistry, these cells were positive for pan cytokeratin and CK7 [Figure 2c].
- Patient showing nodular lesions over the face and lips showing central umbilication with haemorrhagic crusting.
- Dermoscopy revealed polymorphic vessels, multiple dilated tortuous and hairpin vessels arranged peripherally in a radiating fashion with a central keratin plug and pin-point haemorrhages (DermLite™ DL4, polarised mode, 10x).
- Skin biopsy revealed tumour cells arranged in clusters, nests, and cords in the deep dermis and subcutaneous tissue (Haematoxylin & eosin, 40x).
- Skin biopsy revealed tumour cells, oval to round in shape, having vesicular chromatin, a conspicuous nucleolus, and a scant amount of cytoplasm, arranged in clusters, nests, and cords in the deep dermis and subcutaneous tissue (Haematoxylin & eosin, 400x).
- Immunohistochemistry of cells positive for CK7 (100x).
Question
What is your diagnosis?
Answer
Diagnosis: Cutaneous metastasis
18-Fluoro-deoxyglucose positron emission tomography revealed a metastatic carcinoma with the primary tumour in the left lung and metastatic deposits in the pericardium, pleura, retrocrural space, adrenal glands, kidney, skin, subcutaneous tissue, muscle, liver, scrotum, and penis. Prostate-specific antigen (PSA), cancer antigen 19-9 (CA-19-9), carcinoembryonic antigen (CEA), and stool for occult blood were negative.
Cutaneous metastases from internal malignancies are generally rare, occurring in 0.7-10% of oncology cases. Their appearance often indicates advanced disease and is associated with a poor prognosis, with an average survival of three to five months.1 The common primary sites of cutaneous metastases are lung cancer, colon cancer, melanoma, and squamous cell carcinoma (oral cavity), in males, and breast cancer, colon cancer, melanoma, and ovarian cancer in females.2 Cutaneous metastases occur in 1–12% of lung cancer cases, with the highest prevalence observed among male patients. They usually present with firm, painless nodules, with or without ulceration, over the head and neck, chest, and abdomen.1 Cutaneous metastases mimicking keratoacanthoma are very unusual and seldom reported. Reich et al.3 described keratoacanthoma-like cutaneous metastatic lesions on the scalp in lung cancer.
The differential diagnoses considered were disseminated cryptococcosis and cutaneous histoplasmosis, both of which can manifest as umbilicated nodules on the face and extremities in immunocompromised individuals, exhibiting suppurative granulomas on histopathology. Histoid leprosy typically presents as skin-coloured papules and subcutaneous nodules on the face, back, buttocks, and bony prominences, but can also present as umbilicated nodular lesions.4 Cutaneous B-cell lymphoma was also considered in the differential diagnosis. However, the histopathology did not demonstrate characteristic features such as a nodular or diffuse infiltrate of atypical lymphoid cells with germinal centre formation. Immunohistochemistry further helped in differentiation. Cutaneous metastases from internal cancers can exhibit a wide array of clinical presentations, creating substantial diagnostic difficulties in dermatology. Prompt assessment can hence lead to the identification of the primary tumour in many cases like ours.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
References
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