September 2000

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A 34-year-old African American male with sickle cell anemia and a one-year history of Sjogren's syndrome presented with pain and swelling of the left knee. He was started on vancomycin empirically. Arthrocentesis showed no crystals and cultures were negative. Over the next two days, he developed pain and swelling of his right knee and ankle and both shoulders. On the third day following admission, he developed nonpruritic erythema around the site of old hyperpigmented lesions on his upper arms as well as oral ulcers. The patient was otherwise asymptomatic, without evidence of renal or neurological involvement. The patient also developed "bumps" on the extensor surface of the elbows and the volar aspect of the trird fingers approximately two years earlier

Physical Examination: Physical exam revealed a well-appearing African American male with three erythematous annular plaques Fig A), several centimeters in length, on the lateral surface of the upper arms. Blisters were found on the roof of the mouth, and effusions and tenderness were noted in multiple joints. There also were skin colored, firm papules at the volar surface of the third fingers bilaterally and firm subcutaneous nodules on the extensor surface of both elbows.

Laboratory evaluation: Serologies showed ANA positivity with a titer of 1:640, positive Anti-SS-A autoantibodies, and positive RR Anti-SS-B, -Sm, -RNP, and -centromere antibodies were negative.

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