PMC3565908_01
Photograph of the right ankle and foot showing an erythematous papular rash with ulcerations on presentation.
1752-1947-7-20-1.jpg
PMC3565908_01_1752-1947-7-20-1.jpg
F1
An examination revealed hypertension (blood pressure 160/70mmHg), a pansystolic murmur, an aphthous ulcer at the base of her tongue and a rash over her right ankle and foot (Figure  1). The associated skin rash (Figures  1 and 2) did not have a clear role in her presentation but was initially thought to be early Sweet's syndrome associated with a drug-associated vasculitis.
Photomicrograph of the skin biopsy with a hematoxylin and eosin stain x100 showing a heavy neutrophil infiltrate involving the full thickness of the dermis with no evidence of a leucocytoclastic vasculitis.
1752-1947-7-20-2.jpg
PMC3565908_01_1752-1947-7-20-2.jpg
F2
The associated skin rash (Figures  1 and 2) did not have a clear role in her presentation but was initially thought to be early Sweet's syndrome associated with a drug-associated vasculitis.
Photomicrograph of the renal biopsy with a hematoxylin and eosin stain x400 magnification showing a pauci-immune, focal necrotizing glomerulonephritis with one small crescent consistent with anti-neutrophil cytoplasmic antibody-associated vasculitis. Red cell casts are present. There is an interstitial infiltrate of lymphocytes, macrophages and eosinophils which involves some tubules. Immunofluorescence staining revealed mild mesangial deposition of immunoglobulin M and traces of mesangial C3.
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PMC3565908_01_1752-1947-7-20-3.jpg
F3
Hydralazine was withdrawn and the patient underwent a transjugular renal biopsy to confirm the diagnosis (Figure  3).