A 25-year-old man originally from Sudan immigrated to Omaha, Nebraska, after residing in Egypt for the past 4 years. Promptly after arriving in Omaha, he presented to the emergency department seeking care for multiple, painful nodules on his legs. Eight months before admission, the patient had been diagnosed as human immunodeficiency virus (HIV) positive during the immigration screening process, but had not begun antiretroviral therapy nor was he aware of his CD4 count. Four months previously, he had noticed the progressive growth of multiple lower-extremity nodules. These had become much more painful, with a keratotic, pedunculated appearance associated with lower extremity edema (Fig. 1). Inguinal lymph nodes were enlarged but soft, mobile, and nontender. A plain film of the right foot showed periarticular osteopenia and soft tissue swelling. What is your diagnosis?
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