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JAMA Oncology Clinical Challenge
July 23, 2020

A Man With Widespread Arthritis and Ill-Defined Cutaneous Lesions

Author Affiliations
  • 1Division of Oncology, Department of Internal Medicine, Faculty of Medical Sciences, State University of Campinas (UNICAMP)-MA, Campinas, São Paulo, Brazil
JAMA Oncol. Published online July 23, 2020. doi:10.1001/jamaoncol.2020.0826

A man in his 30s presented with a 3-month history of fourth finger right hand articular heat, pain, redness, and swelling. Similar symptoms subsequently spread to the left hallux and ankle, and he developed a fever. Despite many medical consultations and various attempts at treatment with nonsteroidal anti-inflammatories, the patient developed widespread arthritis within the following month, which was predominant in the knee, shoulder, and hip. In the month before presentation the articular symptoms worsened, the joints had become tender, and ill-defined skin nodules had appeared predominantly on the legs (Figure, A and B). An acute abdominal pain in the left hypochondrium developed, accompanied by nausea and vomiting, which led to a diagnosis of pancreatitis. The patient was admitted to the hospital and clinical measures relieved the pain. Laboratory test results revealed strikingly high levels of lipase and amylase, as well as normal levels of cancer antigen 19-9. Bone computed tomography (CT) of the right shoulder and knee demonstrated cortical bone destruction and intraosseous medullary necrosis (Figure, C and D). An abdominal CT was performed (Figure, E), and the patient underwent surgery.

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