A Case of Nodular Rash & Painful Joints

Given the rarity of cutaneous PAN and its predominant distribution among individuals in their 40s or 50s, we considered a wide differential diagnosis for this patient when carrying out our evaluation, including infectious (e.g., disseminated gonococcal infection, syphilis, parvovirus B19 infection, Lyme disease, Rocky Mountain spotted fever, infective endocarditis, septic arthritis, tuberculosis), post-infectious (e.g., reactive arthritis, acute rheumatic fever) and rheumatological (e.g., ANCA-associated vasculitis, cryoglobulinemia, polyarteritis nodosa, sarcoidosis, rheumatoid arthritis, spondyloarthritis, systemic lupus erythematosus, crystalline arthritis) etiologies.⁵

He was ultimately diagnosed with cutaneous PAN via skin biopsy, with high-titer ASO suggestive of antecedent group A Streptococcal infection and possible subsequent rheumatic fever, and his treatment was tailored to this diagnosis. He had no apparent deep organ involvement to suggest a systemic vasculitis. Continued monitoring and heightened awareness are important moving forward, given the often chronic and relapsing course of cutaneous PAN and possible progression to systemic PAN.

Dr. Vania Lin

Vania Lin, MD, MPH, is a rheumatology fellow at Yale School of Medicine, New Haven, Conn.

Dr. Rebecca Johnson

Rebecca Johnson, MD, recently completed the Dermatopathology Fellowship Program at Yale School of Medicine, New Haven, Conn.

Dr. Suter

Lisa Suter, MD, is a professor of medicine in the Section of Rheumatology at the Yale School of Medicine, New Haven, Conn.; she is also director of quality measurement programs at the Yale New Haven Health Services Corporation Center for Outcomes Research and Evaluation (CORE).

Disclosures

Outside the submitted work, Dr. Suter receives support for directing a federal contract, the Measure & Instrument Development Support (MIDS) contract; Development, Reevaluation and Implementation of Outcome/Efficiency Measures for Hospital and Eligible Clinicians, funded by the CMS; and during the conduct of the study, grants from Brigham and Women’s Hospital (BWH). Dr. Suter received $5,000 or less per year in consulting fees to Dr. Losina, PI, on an NIH grant through BWH to study knee osteoarthritis.

References

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