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Erythematous Papules and Hemorrhagic Vesicles in a Woman With Arthralgias and Eye Pain

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

A 48-year-old woman with diet-controlled diabetes presented with a 6-month history of arthralgias in her hands, feet, elbows, and knees; 3 weeks of a purpuric rash and foot paresthesias; and 2 weeks of bilateral eye pain and redness. She had been prescribed 4 days of prednisone (10 mg/d) without improvement. She had no fevers, epistaxis, rhinorrhea, cough, shortness of breath, or hematuria. She had no history of recent travel or illicit drug use and was not taking any medications.

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ANCA-associated vasculitis

A. Check antineutrophil cytoplasmic antibody (ANCA) titers

The key to the correct diagnosis is the history of arthralgias, paresthesias, ocular inflammation, palpable purpura, and skin biopsy findings of leukocytoclasia, which is characteristic of small vessel vasculitis. ANCA-associated vasculitis due to granulomatosis with polyangiitis was confirmed with serum indirect immunofluorescence, diffuse cytoplasmic staining ANCA (c-ANCA) (+1:20), and a positive proteinase 3 (PR3) antibody (+51.8).

Chikungunya (choice B) is a mosquito-borne viral illness that may cause arthralgias and conjunctivitis; however, its rash is morbilliform rather than purpuric. Obtaining a transthoracic echocardiogram (choice C) is incorrect because without fevers or history of intravenous drug use, endocarditis is unlikely. While Chlamydia trachomatis (choice D) may cause a reactive arthritis with arthralgias and conjunctivitis, it does not cause cutaneous small vessel vasculitis.

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Article Information

Corresponding Author: Cristina Thomas, MD, Department of Dermatology, UT Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9069 (cristina.thomas2@utsouthwestern.edu).

Published Online: November 10, 2021. doi:10.1001/jama.2021.18708

Conflict of Interest Disclosures: None reported.

Additional Contributions: We thank the patient for providing permission to share her information.

References
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