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A 37-Year-Old Man Comes to the Physician with Nodules on His

question 764

Multiple Choice

A 37-year-old man comes to the physician with nodules on his hand and forearm. The nodules first appeared about 2 weeks ago on the dorsal aspect of his right index finger. Initially, a small papule formed and drained some clear, odorless material. There was minimal associated pain. The nodule persisted and several days later two other similar nodules formed over the dorsal aspect of his right wrist and distal arm. He has no fever, chills, or constitutional symptoms. The patient works as a landscaper and has installed a lot of moss in terraced yards over the past month. He also hunts and within the past month has dressed rabbits that he has shot. He is in good health, takes no medications, and has no HIV risk factors.
Vital signs are normal. Cardiopulmonary, abdominal, and neurologic examinations are normal. There are 3 tender papules on top of the dorsal aspects of the right index finger, wrist, and the distal right upper extremity. One open nodule has a small crust on the top. There are no other cutaneous lesions and no adenopathy.
A sample is obtained for biopsy and culture. The biopsy shows mixed pyogenic and granulomatous inflammation. Gram stain, acid-fast/partial acid-fast, silver methenamine, and periodic acid-Schiff stains (PAD) are negative. Cultures are pending.
What is the most likely diagnosis in this patient?

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