A 59-Year-Old Woman With Painful Rash on Her Elbows

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


August 03, 2023

Physical Examination and Workup

Upon physical examination, the patient had multiple nonblanching nodules in a linear pattern involving the upper extremities, inclusive of the elbows, forearms, and multiple metacarpophalangeal joints of both hands (Figure 1). No plaques or petechial rashes were noted at that time.

Figure 1.

Over the next 2 years, multiple RA-associated nodules appeared, along with a worsening in the rash (Figure 2).

Figure 2.

She remained noncompliant with her drug regimen. Multiple avenues of social assistance were exhausted in trying to assist her with her disease process. New ulcerations on her lower extremities appeared over time, which were managed by vascular surgeons who found evidence of dry gangrene. Small ulcerations were also present at her fingertips (Figure 3).

Figure 3.

The ulcerations and dry gangrene required the DMARDs to be withheld temporarily to allow the ulcerations to heal. She continued to have frequent and severe RA flares with joint stiffness and widespread pain, requiring daily prednisone.

When her wounds began to heal, she was contacted multiple times to restart her DMARDs; however, she continued to miss her regularly scheduled appointments and stopped taking the medications prescribed to her. As time went on, she was found to have a worsening mottled, erythematous, nonblanching, palpable nodular lesion on the plantar portion of her left heel. She then presented to the emergency department febrile, with altered mental status. Her laboratory findings were significant for a positive rheumatoid factor test result, elevated erythrocyte sedimentation rate of 91 mm/hr, C-reactive protein level of 17.1 mg/L, white blood cell count of 13.1 × 109/L, hemoglobin level of 9.6 g/dL, and hematocrit concentration of 30.8%.

She was hospitalized and treated with intravenous antibiotics. Tissue from the wound, which extended to the bone, revealed osteomyelitis. However, the presentation of multiple palpable, nonblanching lesions on both her upper and lower extremities was of greater concern. These lesions had significantly worsened from initial presentation, and biopsies were obtained upon hospitalization.


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