Rheumatology Case Quiz Collection: Fevers, Rashes, Nodules

March 5, 2015

Not all cases with rheumatic disease turn up in the rheumatology literature, of course. Test your diagnostic skills on these four puzzlers from other journals. (We present brief descriptions only, with hyperlinks to the original reports.)

S. Christenson, ES, Ligon, C, Hsu S. A Wolf in Infection's Clothing: The Difficulties of Discerning Systemic Lupus Erythematosus from its Infectious Sequelae American Journal of Medicine. 2015 doi: 10.1016/j.amjmed.2015.01.017

A 58-year-old South Asian woman initially presented with lupus masquerading as a diarrheal illness that delayed her diagnosis. Prednisone and mycophenolate mofetil were prescribed.

The patient was readmitted later with multi-organ disease and declining mental status, with intermittent fevers.

Echocardiography showed depressed left ventricular systolic function.

What pattern do you see?

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Desai S, Keimig E. Stellate Red-Brown Patches on the Distal Extremities. JAMA Dermatology. 2015. doi:10.1001/jamaDermatology.2014.4479

A woman in her 40s presented with a 1-year history of asymptomatic red-brown patches which began on the lower legs and spread to the thighs, buttocks, hands, forearms, and arms. They were stellate red-brown patches without induration, scale or ulceration. She had muscle cramping and numbness on the lower extremities.

Why did the dermatologist refer her to you?

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Unizony SH, Kim ND, Hoang MP. A 25-Year-Old Man with Oral Ulcers, Rash, and Odynophagia. New England Journal of Medicine. 2015; 372:864-872. doi: 10.1056/NEJMcpc1413303

This patient, who was sexually active with multiple partners, had oral and genital ulcers and erosions, fever, myalgias, and cervical lymphadenopathy. He also had two types of skin lesions, a papulopustular, acneiform rash and red, tender nodules resembling erythema nodosum.

The fever, rash, myalgias, lympadenopathy, and pharyngitis were similar to syphilis, but the pustular rashes and deep ulcerations were not. Other skin disorders didn’t match the type or distribution of the skin lesions.

On the second hospital day, he developed new bilateral knee pain with mild joint inflammation.

He had a family history of inflammatory bowel disease.

What's your guess at the diagnosis?

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Long KA, Braudis K, and Brown B. New Tender Nodules After Arthroscopy QUIZ
http://archderm.jamanetwork.com/article.aspx?articleid=2091957
JAMA Dermatol. Online January 28, 2015. doi:10.1001/jamadermatol.2014.4872

A woman in her 20s with systemic lupus erythematosus presented with tender erythematous nodules on the right knee after arthroscopy.

At first, it looked like a soft tissue infection, and was treated with clindamycin, vancomycin and doxycycline, but that didn’t help.

Closer examination showed tender erythematous plaques and nodules, from the thigh to the lower leg, adjacent to the arthroscopy sites, and around the suture sites.

Did the punch biopsy reveal

­­­-- Cellulitis?

-- Tumid lupus erythematosus?

-- Gyrate erythema?

-- Erythema nodosum?