Rheumatology Case Challenge: A 54-Year-Old Woman With Discolored Toes and Nonhealing Ulcers

Kelsey N. Rigby, DO


April 27, 2023

Physical Examination and Workup

Upon physical examination, the patient appears well and is alert and oriented. Her vital signs include a blood pressure of 133/58 mm Hg, a heart rate of 92 beats/min, and a temperature of 97.5 °F (36.4 °C). Her height is 5 ft 2 in, and her weight is 236 lb (107 kg); her body mass index is 43.2.

Her sclera is not icteric, and her mucosal membranes are moist. No oral or nasal ulcers or polyps are evident. No cervical lymphadenopathy is noted.

Her heart rate and rhythm are regular; no murmurs, rubs, or gallops are detected. Her lungs are clear to auscultation, without adventitious sounds. Her abdomen is soft and nontender; no hepatosplenomegaly or masses are noted.

The skin examination reveals livedo reticularis of the bilateral lower extremities, with associated erythema of the feet. An approximately 1 × 1 cm shallow ulcer at the distal aspect of the second digit of the right lower extremity is noted (Figure 1). On the medial aspect of the right foot, multiple small (approximately 0.5 × 0.5 cm), immobile, firm, nontender pink nodules are present (Figure 2). A complete joint examination of the appendicular skeleton shows no warmth, joint swelling, tenderness, or overlying skin changes, except those noted on the lower extremities.

Figure 1.

Figure 2.

Punch biopsy of a nodule on the medial aspect of the right foot is obtained. The pathology report is significant for fibrinoid necrosis of the vessel wall of a medium-sized muscular artery in the deep dermis, with a mixed infiltrate that consists of neutrophils, lymphocytes, and histiocytes (Figures 3 and 4). Elastic van Gieson staining shows disruption of the internal elastic lamina of the vessel wall (Figure 5). Luminal thrombotic occlusion is not observed.

Figure 3.

Figure 4.

Figure 5.


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