The American Society of Dermatopathology

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Interactive Case Study - April 2018

Hemorrhagic lesions in a female with systemic lupus erythematosus

Viktoryia Kazlouskaya, MD, PhD; Ellen M. Ginzler, MD; Edward R. Heilman, MD; Silvija P. Gottesman, MD, FAAD

Question 1:

A 40-year-old female patient with a known history of systemic lupus erythematous undergoing treatment with mycophenolate mofetil and prednisone was admitted to the hospital with a chief complaint of shortness of breath for more than two weeks. She denied recent travel and sick contacts. The patient was febrile and radiographic images confirmed pneumonia. Unfortunately, her condition worsened; she developed respiratory failure and required intubation for respiratory support. While in the intensive care unit (ICU), she developed oliguria, renal failure and subsequently hemodialysis was started. Several days into her admission, she developed ulcerated lesions on the forearms, which had necrotic eschars centrally with a rim of purpura peripherally (Figure 1). Biopsy from one of the lesions was taken, and representative sections are shown below (Figures 2-6).
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Figure 1

Figure 2

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Figure 6

What is the most likely diagnosis?