“ID” the Images

37 year old farmer in Iowa who developed some papules on his knees that would not respond to frequent washings, antibiotic creams, and oral medications such as Keflex. This continued for several weeks until he noticed a somewhat necrotic ulceration over his right hip.

His duties on the farm included planting corn and soybeans and a small herd of cattle. He grew grasses for hay baling, which would require him to load the bales onto a tractor wagon and store them in a barn.

He denied any fever or chills. He had no headache respiratory, or GI/GU complaints. After a visit to his primary care physician, routine tests were ordered. His CBC, CMP, UA, and CXR were all unremarkable.

A lesion on his knee (left) and a lesion on his hip (right) are shown in the image.

The patient had a biopsy of the lesion on his hip. Which of the following on biopsy would confirm the diagnosis?