Woman With Left Shoulder Bumps

A 40-year-old woman presented to the emergency department (ED) for left shoulder and right-sided neck “lumps” that developed during several weeks. She was initially asymptomatic and without other complaints, and incision and drainage with sample culture of the shoulder lesion did not reveal any bacteria. Further incision and drainage of the neck was then deferred ( Figure 1 ). She was instructed to follow up with her primary care physician and a dermatologist, but instead returned to the ED 3 weeks later with a productive cough, night sweats, and new smaller lesions over her right shoulder. Computed tomography (CT) scan of the chest ( Figure 2 ), neck, and abdomen were obtained. A dermatology consultant obtained a punch biopsy and sent samples for further analysis ( Figures 3 to 5 ) to confirm the diagnosis.