Female with subcutaneous nodules and livedo racemosa: Case r
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A 23-year-old female presented with painful upper and lower extremity lesions and fatigue. She denied neurologic, pulmonary, cardiac, renal, gastrointestinal, and musculoskeletal symptoms on review of systems. Clinical examination revealed bilateral lower extremity tender subcutaneous nodules and upper extremity livedo racemosa. Punch biopsy revealed perivascular lymphohistiocytic infiltrate, extravasated RBC, and a necrotic blood vessel at the dermal-subcutaneous junction. Vitals were within normal limits and laboratory investigations were unremarkable except for an elevated ESR.

Cutaneous polyarteritis nodosa was confirmed on diagnosis. Tender subcutaneous nodules, livedo racemosa, and biopsy demonstrating a necrotic blood vessel at the deeper, dermal subcutaneous junction suggests a medium-vessel vasculitis. Perivascular lymphohistiocytic infiltrate and concentric layers of fibrosis signifies the lesion is greater than 48 hours old and in the reparative stage. Fatigue, weight loss, fever, arthralgias, and neuropathy can be present in both cutaneous and systemic polyarteritis nodosa (c-PAN and PAN, respectively); however c-PAN lacks multiorgan system involvement including hypertension, abdominal pain, renal failure as well as
hematuria and microaneurysms on laboratory studies and imaging, respectively.

Oral corticosteroids may be used for acute flares of cutaneous polyarteritis nodosa, particularly when there are extracutaneous symptoms present. Additional agents including hydroxychloroquine, azathioprine, methotrexate and cyclophosphamide may be used in conjunction with corticosteroids or following corticosteroid taper in patients with refractory or more severe disease. For mild cases NSAIDS, colchicine, topical or intralesional steroids may also be effective.

source: https://www.jaadcasereports.org/article/S2352-5126(20)30746-3/fulltext?rss=yes
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