March 2017






HPI: 56-year-old Caucasian female with a PMH significant for rheumatoid arthritis (on methotrexate, leflunomide, and Orencia), presented to the hospital for new onset pancytopenia and dermatology was consulted for rash and mouth lesions.  Patient had non-healing lesions on her left index finger that appeared three months prior to admission with history of injuring the finger on rose thorns in her garden.  She also developed lesions on her right knee, left foot, and right first and third fingers.  Patient endorsed that lesions had been growing and were painful.  She denied any draining or bleeding from lesions.  Prior to admission, patient had taken multiple courses of antibiotics including amoxicillin, Keflex, and Bactrim with no improvement.

PMH: EGD to remove foreign body, irrigation and debridement of the abdomen

Social Hx: Single, current everyday tobacco smoker 1 pack per day, denied alcohol use and denied illicit drug use.  No recent travel history.

Family Hx: No significant family history.

Allergies: No known drug allergies.

Medications:Acyclovir 400mg BID,Aspirin 81mg QD, Folic Acid 2mg QD, Gabapentin 600mg QD,Lisinopril 20mg BID,Methotrexate 20mg every week

Orencia 2mL IV once a month, Proventil HFA 1-2 puffs q4h PRN

Ranitidine 150mg 1 tab BID, Sertraline 100mg 2 tablets QD

Trazodone 100mg 1-3 tablets QD, Atorvastatin 40mg QD

Leflunomide 10mg QD


Laboratory Results:

T 36.6/RR 16/SpO2 99/HR 66/BP 97/42

CBC WBC 1.87/Hgb 7.5/Hct 22.5/Plt 29

CMP Na 137/K 4.5/Cl 105/CO2 23/BUN 21/Cr 0.90

Coag PTT 33.2/PT 12.1/ INR 1.12

LDH 150


Tissue culture acid-fast bacilli, negative, Aerobic culture/gram stain, negative,Fungal culture, negative

Urine histoplasma antigen, negative

Blood acid-fast bacilli culture, negative, Blood fungal culture, negative, Blastomycosis antibody, negative

Serum histoplasma antibody, negative, CMV antibody, negative

HIV, negative,EBV antibody, negative

Erlichia antibody, negative,Parvovirus antibody, negative

Methotrexate level 0.05

HSV 1 and 2 antibodies, negative, HSV PCR oral culture, negative



Physical Exam: 2cm wide red-brown verrucous-crusted nodule with surrounding erythema on the left 2nd PIP joint.  Approximately, 1cm pink papule with central brown crusting on the right knee.  In addition, there were numerous other similar appearing smaller lesions 4-10mm on the left dorsal foot and right 1st and 3rd fingers (Figs 1-6).  There were also punched out superficial ulcers on the right buccal mucosa and left upper hard palate without drainage or exudate.

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