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Answers on p243.
A 61 year old white homosexual man complained of profound fatigue, proximal lower extremity weakness, myalgias, and fever of two days' duration. He also complained of a worsening rash over his proximal upper extremities, trunk, and back for the past month. Two months earlier he had been diagnosed with seronegative rheumatoid arthritis when he presented with bilateral hand and wrist pain. He denied cough, shortness of breath, photosensitivity, Raynaud's phenomenon, dry mouth or eyes, recent travel, pets, morning stiffness, penile discharge, or genital ulcers. He tested HIV negative three months before admission. His past medical history was significant for hypertension, gastro-oesophageal reflux disease, and obstructive sleep apnoea. He had been taking prednisone 15 mg and cimetidine 400 mg daily.
On examination, the patient looked acutely ill and uncomfortable. He was febrile at 102.4°F, his blood pressure was 148/80 mm Hg, and his pulse was 90 beats/min. He had confluent erythematous and purpuric plaques on his back, anterior trunk, and proximal upper extremities (see fig 1); some were in a polycyclic arrangement but without scale. No muscle tenderness or weakness was detected. There was no appreciable arthritis or synovial thickening. He had a II/VI systolic murmur throughout his precordium without radiation. The remainder of his physical examination was without abnormalities.
The initial evaluation is listed in box 1. A skin biopsy showed superficial and deep perivascular infiltrates with extensive interface damage. Immunofluorescence revealed strong granular C3 and trace granular IgG and IgM at the dermal-epidermal junction.
(1) What diagnoses would be consistent with the results of the skin biopsy?
- What are the cutaneous lesions of lupus erythematosus?
- Does he meet criteria for the diagnosis of systemic lupus erythematosus (SLE)?
- How common is SLE in patients of this age, race, and gender?
- As the patient was at risk for HIV infection, what dermatological manifestations of HIV should be considered?
Box 1: Initial evaluation
White blood count = 2.6 × 109/l
Haemoglobin = 145 g/l
Platelet count = 143 × 109/l
Electrolytes, blood urea nitrogen, creatinine, urinalysis, calcium, albumin = normal
Alkaline phosphatase, bilirubin normal
Aspartate aminotransferase = 60 U/L
Alanine aminotransferase = 56 U/L
Aldolase, creatine phosphokinase normal
Erythrocyte sedimentation rate = 50 mm/hour
Antinuclear antibody positive at 1:160
IgM anticardiolipin antibody positive
Rheumatoid factor positive at 1:1280
Venereal Disease Research Laboratory non-reactive
Anti-Ro, anti-La, antiribonuclear protein, anti-Sm, antidouble stranded DNA, anticentromere antibodies negative
C3, C4, CH50 concentrations normal
Quantitative serum HIV RNA by polymerase chain reaction negative
Blood cultures negative
Electromyography with nerve conduction studies normal
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