Rheumatology Case Challenge: A 56-Year-Old With Swollen Ears, Facial Rash, and Shoulder Pain

Diana M. Girnita, MD, PhD


March 13, 2023

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.


A 56-year-old woman presents to her dermatologist with a small left preauricular erythematous lesion (Figure 1). Doxycycline is prescribed. After she takes the antibiotic for 2 weeks without improvement, a skin biopsy of the lesion is obtained, and hydrocortisone cream is prescribed. Within a week, the lesion fades and disappears.

Figure 1.

Later that month, the patient develops left aural edema (Figure 2), with no associated pain, erythema, or drainage. She applies the same hydrocortisone cream, and the edema improves.

Figure 2.

The following month, painless warmth and swelling develop on her right ear pinna (Figure 3). The swelling persists despite the use of hydrocortisone cream. Her dermatologist orders laboratory tests and performs a shave biopsy from the right ear. The antinuclear antibody (ANA) test is positive, and the patient is referred to a rheumatologist.

Figure 3.

The initial visit to the rheumatologist occurs 3 months after the onset of symptoms. Examination reveals persistent swelling of the right pinna; however, the facial rash and left ear swelling have completely resolved. At this visit, she reports mild xerostomia and xerophthalmia, for which she uses over-the-counter eye drops as needed. She also describes intermittent right shoulder pain. A comprehensive rheumatologic review of systems is negative for other symptoms.

The patient has a past medical history of hyperlipidemia and seasonal allergies. She has two dental implants, and her surgical history includes a lumbar laminectomy 9 years ago. No significant family history is reported. Her current medications are simvastatin daily, loratadine daily as needed, and topical hydrocortisone cream as needed.


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