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A white man in his 30s with a 7-year history of severe, mechanical, low back pain and long-standing mental depression was referred to the dermatology department for evaluation of an asymptomatic cutaneous ulcer that had developed over the past year. Physical examination disclosed a large and deep, irregularly shaped, cutaneous ulcer on the dorsum of his right forearm. Necrotic tissue and muscle exposure was seen at the base of the ulcer (Figure, A). Woody induration of skin on both forearms and on the abdominal region was also observed. Bilateral contracture of deltoid, triceps, and biceps muscles was noted. Active and passive range of motion was restricted at the shoulders and elbows. No signs of joint inflammation were seen. At the time of consultation, the patient was taking oral treatment with duloxetine hydrochloride, clonazepam, oxcarbazepine, fentanyl, sulpiride, zopiclone, omeprazole magnesium, and baclofen. He also admitted to self-administering subcutaneous injections of meperidine, 100 mg 4 times per day, for the past 3 years, at different sites, including the deltoid areas and abdomen. Growth from culture specimens taken from the ulcer was negative for bacteria, mycobacteria, and fungal organisms. His serum creatinine kinase level was raised (192 U/L; reference range, 0-174 U/L), but test results for complete blood cell count; erythrocyte sedimentation rate; antinuclear antibody, rheumatoid factor, aspartate aminotransferase, alanine aminotransaminase, and aldolase levels; and serum electrophoresis were all within normal limits. A wedge biopsy from the indurated skin of the abdominal region was performed (Figure, B and C). (To convert creatinine kinase to microkatals per liter, multiply by 0.0167.)
Rozas-Muñoz E, García-Muret MP, Puig L. Chronic Ulceration and Fibrosis of the Forearm. JAMA Dermatol. 2015;151(3):331-332. doi:10.1001/jamadermatol.2014.2826