Ability of rheumatologists to diagnose RA only by clinical assessment arthritis from early-onset undifferentiated arthritis. Clin Exp 23 Wakefield RJ, Green MJ, Marzo-Ortega H et al. Should Rheumatol 2010;28:68694. oligoarthritis be reclassified? Ultrasound reveals a high prevalence of subclinical disease. Ann Rheum Dis 21 Tamas MM, Rednic N, Felea I, Rednic S. Ultrasound as- 2004;63:3825. sessment for the rapid classification of early arthritis pa- tients. J Investig Med 2013;61:118491. 24 Mangnus L, van Steenbergen HW, Reijnierse M, van der 22 van de Stadt LA, Bos WH, Meursinge Reynders M et al. Helm-van Mil AH. Magnetic resonance imaging-detected The value of ultrasonography in predicting arthritis in auto- features of inflammation and erosions in symptom-free antibody positive arthralgia patients: a prospective cohort persons from the general population. Arthritis Rheumatol study. Arthritis Res Ther 2010;12:R98. 2016;68:2593602. Rheumatology 2018;57:1601 doi:10.1093/rheumatology/key084 Clinical vignette Advance Access publication 28 March 2018 FIG.1 Bullous lesions in a patient with SLE: gross appearance and histopathology A 15-year-old girl had a 4-month history of fever, arthritis of the elbows, left knee and left ankle, and maculopapular rashes with bullae on the neck, chest and abdomen (Fig. 1A and B). Anasarca, pallor, ulcers on the hard palate, matted cervical lymphadenopathy and mild hepa- tosplenomegaly were present. Haemoglobin was 6 g/dl; direct and indirect Coombs tests were positive; serum ANA and anti-dsDNA levels were elevated; 24-h urinary protein was 1.89 g. Renal biopsy showed diffuse [International Society of Nephrology (ISN)/Renal Pathology Society (RPS) grade 4] LN. Cervical lymph node biopsy revealed reactive Bullous lesions on the neck and abdomen (A and B); hyperplasia. Skin biopsy showed intra- and subepidermal photomicrograph of skin biopsy showing intra- and sub- cleft formation, pigmentary incontinence and mild inflam- epidermal blisters (C, haematoxylin and eosin); immuno- matory perivascular infiltrate (Fig. 1C). On DIF, linear de- fluorescence showing linear deposition of IgG in the base posits of IgG and IgA were seen at the dermoepidermal of the blisters (D, DIF). junction (Fig. 1D). She was given high-dose CS and 6-monthly pulsed doses of i.v. CYC, followed by AZA and HCQ whereupon there was improvement in symptoms. Bullous lupus may Disclosure statement: The authors have declared no or may not be associated with systemic activity; when conflicts of interest. present, it is usually in the form of nephritis and haemato- 1 1 2 Mohammad Ali , Ashish Sharma , Arvind Ahuja logical involvement. Dapsone is the treatment of choice for and Vivek Arya the bullous disease; however, where control of visceral 1 2 disease is simultaneously required, higher-than-usual Department of Medicine and Department of Pathology, Postgraduate Institute of Medical Education and Research, Dr doses of CS and other immunosuppressants can achieve Ram Manohar Lohia Hospital, New Delhi, India control of both. Funding: No specific funding was received from any Correspondence to: Mohammad Ali, C-322, Yojana Vihar, bodies in the public, commercial or not-for-profit sectors Delhi 110092, India. to carry out the work described in this manuscript. E-mail: email@example.com The Author(s) 2018. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For permissions, please email: firstname.lastname@example.org https://academic.oup.com/rheumatology 1601 Downloaded from https://academic.oup.com/rheumatology/article-abstract/57/9/1601/4955853 by Ed 'DeepDyve' Gillespie user on 28 August 2018
Rheumatology – Oxford University Press
Published: Sep 1, 2018
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