A 59-Year-Old Woman With a Painful Rash and Fingertip Ulcerations

Victoria M.F. Mank, MD; Jefferson R. Roberts, MD

Disclosures

October 11, 2019

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

A 59-year-old white woman presented with a pruritic and painful rash on her elbows, overlaying her rheumatoid nodules. Her past medical history was significant for aggressive seropositive rheumatoid arthritis (RA), poorly controlled type 2 diabetes mellitus, hypothyroidism, and fibromyalgia. Her prescribed treatment at that time was etanercept, leflunomide, and prednisone. However, she frequently self-discontinued medications and did not attend scheduled appointments. Multiple other disease-modifying antirheumatic drugs (DMARDs) were attempted prior to the current combination. These medications included methotrexate, hydroxychloroquine, sulfasalazine, adalimumab, and infliximab.

The rash overlaid her rheumatoid nodules on her elbows and forearms and had worsened, increasing in size and severity, involving her lower extremities and including the bases of her feet and shins since she self-discontinued etanercept. She smoked one pack of cigarettes per day for several years and had polysubstance drug abuse.

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