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  Diagnostic Quizzes
A patient with Sjögren’s syndrome
A 63-year-old woman presented with multiple tender, nonulcerating, erythematous nodules on her right hand and forearm
for 10 days (Figure 1A). She was suffering from Sjögren’s syndrome for more than 1 year and had been treated continually with
azathioprine and prednisolone. Under the tentative diagnosis of erythema nodosum, an incisional biopsy was performed
on her right forearm. Histopathology showed septolobular panniculitis, heavy infiltrates of neutrophils and granulomatous
inflammation (Figures 1B and 1C). Periodic acid-Schiff (PAS) and acid-fast stains were negative. She was then treated with
prednisolone 20 mg per day for suspected autoimmune panniculitis. The patient returned to our clinic 2 months after initial
presentation. Multiple erythematous to purpuric macules, papules, and punched out ulcers spread centripetally over the
patient’s four extremities in a symmetrical distribution (Figure 2A). Tender erythematous nodular eruptions without ulcerations
similar to her previous skin lesions at initial presentation were found over both hands and forearms (Figure 2B). There were no
associated systemic symptoms, such as fever, chilling and myalgia. She was treated with higher dose of prednisolone of up to
60 mg per day for suspected autoimmune vasculitis by the rheumatologist. However, more papulonodules, ulcers and pustules
developed over her extremities as we tapered the dose of systemic steroid. Another skin biopsy of a fresh pustule from her
right hand was taken and submitted for both histopathology and culture. Acid-fast positive bacilli were found (Figure 3).


fig 1


fig 2
pustules and crusted lesions

fig 3

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