A 47-year-old woman presented with a 7-month history of multiple painful erythematous plaques on her lower legs. The lesions appeared as erythematous nodules on the left leg with tenderness and pruritus and rapidly progressed to both legs. Marked lower-leg edema was noted 20 days prior to the visit. She also had an intermittent fever during the past 3 months that did not respond to antibiotic therapy. The patient’s medical history was unremarkable.
Physical examination revealed ill-defined, indurated erythematous-violaceous plaques on the lower extremities with substantial edema (Figure, A and B). Complete blood cell count revealed a normal white blood cell count with moderate anemia (hemoglobin level, 87 g/L; normal range 115-150 g/L). Additional laboratory tests demonstrated an elevated level of serum lactate dehydrogenase (749 U/L; normal range 100-240 U/L) (to convert to μkat/L, multiply by 0.0167). Quantification of Epstein-Barr virus (EBV) DNA in sera showed a high viral load of EBV in peripheral blood (1 800 000 copies/mL, normal range <500 copies/mL). A skin biopsy specimen was obtained from a violaceous plaque (Figure, C).