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February 2011February 21, 2011

Longstanding Painful Hemorrhagic Vesicles and Erosions on the Lower Leg—Quiz Case

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Arch Dermatol. 2011;147(2):235-240. doi:10.1001/archdermatol.2010.426-a

A 73-year-old man with rheumatoid arthritis and undergoing long-term immunosuppressive therapy with methotrexate presented with a 6-month history of painful hemorrhagic vesicles and erosions on the right lower leg. Previous clinical and histologic examinations suggested leukocytoclastic vasculitis. Subsequent treatment with oral prednisolone, 20 mg/d, reduced the pain while the lesions progressed. After pneumonia developed that was not responsive to oral moxifloxacin treatment, pulmonary involvement of the rheumatoid arthritis was suspected. Intravenous cyclophosphamide, 1g, in combination with an increase in the oral prednisolone dose to 40 mg/d led to disappearance of the pulmonary infiltration, but skin lesions further spread, and the patient was referred to our department.

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