CLINICAL

CASE 2

A 65 year-old, White female, homemaker, from juazeiro-Bahia-Brazil, presented to the clinic
with a history of approximately two years with pain and swelling on her left
metatarsoplalangeal and right metacarpophalangeal joints, that progressively evolved to
the right foot, left hand, ankles and wrists. She is known to have diabetes mellitus type 2,
treated with oral hypoglucemic drugs, and in control. The patient denied any alcohol or
illicit drug use and was a lifelong non-smoker.

She consulted several orthopedists for her pain and was being medicated with prednisone
and nonsteroidal anti-inflammatories (NSAIDs), a few months ago she was referred to a
rheumatologist, that diagnosed her as having rheumatoid arthritis (RA) and continued
prednisone and NSAIDs. In continuous use of prednisone (20mg/day), she presented
erythematous nodules on face, upper and lower limbs, paresthesia on feet and hands, and
worsening of articular pain and edema.

A few days latter, she presented fever, worsening of the lesions and articular pain, being
hospitalized and diagnosed as eruptions induced by drugs and RA, and referred to a
dermatologist. On admission, her blood pressure was 106/68 mm/Hg, her temperature was
38.5C, her respiratory rate was 26 breaths/minute, and her pulse rate was 88
beats/minute. A physical examination revealed an ill-looking woman with mucosal pallor,
generalized wasting and non-tender, rubbery axillary and inguinal lymphadenopathy. We
noticed skin affection: erythematous-purplish plaques, erythematous papules and nodules,
on face, trunk, upper limbs and lower limbs. Her hands were edematous and she had
arthritis of small joints in her right hand and right feet. There was no evidence of cyanosis,
digital clubbing, pitting edema, skin rash or joint deformities. Her abdomen was mildly
distended but non-tender, with no organomegaly detected. The cardiovascular, respiratory
and neurological examinations were unremarkable.


Laboratory test results included: CBC reported 14,900 WBC, with 46% of lymphocytes (up
to 39%). Liver and kidney function tests, C-reactive protein, protein electrophoresis, VDRL,
urinalysis, glycemia, normal. Rheumatoid factor was positive but anti-cyclic citrullinated
peptide antibodies (ACPA) were negative. Serology for Leishmaniasis and culture for fungi
were negative. One of the lesions in her skin was biopsied and the anatomopathological
examination showed pseudoepitheliomatous hyperplasia, macrophages with wide
vacuolated cytoplasm and the presence of granulomas. Search for acid-fast bacilli using
Ziehl-Nielsen staining was positive.