BENJAMIN D. Schwartz, MD, PhD, Associate Professor of Medicine, Washington University School of Medicine; Investigator, Howard Hughes Medical Institute Laboratory, St Louis: A 59-year-old woman was admitted to our hospital because of recurrent digital ulcerations. Rheumatoid arthritis, diagnosed 27 years previously, had been relatively successfully controlled by 17 years of chrysotherapy, nonsteroidal anti-inflammatory agents, and prednisone administration. Three years prior to admission, a cavitary lesion was noted on a chest roentgenogram, and a sputum culture specimen disclosed Mycobacterium tuberculosis. The patient was treated with isoniazid, rifampin, and ethambutol hydrochloride. Her hospital course was complicated by cholelithiasis requiring cholecystectomy, and by postoperative pulmonary emboli that were refractory to anticoagulation therapy. Eventually she required insertion of an inferior vena caval umbrella.
Two years prior to admission, gangrene of the fourth finger of the right hand, several digital ulcerations, and purpura on the right leg had developed. Rheumatoid factor was present at a