PMC8604493_01
Large ragged painful ulcer with significant surrounding erythema on the left pretibial area
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On examination, a 4 cm x 3.5 cm ragged moist ulcer with surrounding erythema, edema, tenderness, and significant serous drainage was noticed on the left distal pretibial leg. (Figure 1:photo of leg dated 3/10/2020) The differential diagnosis for this refractory ulcer was broad, including infectious causes (bacterial, fungal, and non-tuberculous mycobacterial) and non-infectious conditions such as vasculitis, pyoderma gangrenosum, and squamous cell carcinoma.
A 30 cm x 30 cm well- defined painful bright pink circular patch centered around the anus
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Examination revealed extremely large and inflamed external hemorrhoids and a sharply defined 30 cm x 30 cm circular patch of skin centering around the anus, extending to the perineum, inguinal creases, medial buttocks, and labia majorae with maceration and significant serous drainage from the immediate perianal area (Figure 2) (4/21/2020).
Skin biopsy from the buttock demonstrates that eosinophilic predominant infiltrates comprised of perivascular inflammatory cuffs with a lymphohistiocytic component in addition to numerous eosinophils with diffuse interstitial eosinophilic infiltrates in the mid and lower dermis (4 x) (a). (b) 10x. (c) 40x
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There were also diffuse interstitial eosinophilic infiltrates in the mid and lower dermis [Figure 3(a-c)].
Arm redness, bruising after trauma
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Examination revealed extremely large and inflamed external hemorrhoids and a sharply defined 30 cm x 30 cm circular patch of skin centering around the anus, extending to the perineum, inguinal creases, medial buttocks, and labia majorae with maceration and significant serous drainage from the immediate perianal area (Figure 2) (4/21/2020). Five months, later she had trauma to the left arm that led to severe arm redness, bruising and skin tear [Figure 4(a)] that initially healed, but later, she developed severe pain, redness at the site of injury (Figure 4(b)) and her symptoms were similar to the previous WS flare; she was treated with steroid and symptoms improved significantly and successfully tapered off steroids in fourweeks.