PMC8485840_01
Macular violaceous erythema over the bilateral extensor hands in a
patient with dermatomyositis on the dorsal surfaces of both hands.
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Ch1.F1
A rash consistent with dermatomyositis was present on the chest, shoulders, forearm and dorsal aspect of both hands over the MCP joints (see Fig. 1).
Axial post-contrast T1-weighted fat-suppressed images at the level
of the wrist (a) and metacarpal heads (b) demonstrate irregular thickened
tenosynovial enhancement involving the extensor tendons of the
second to fifth fingers (white arrows). The flexor tendons are normal by
comparison.
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Ch1.F2
T1-weighted fat-suppressed magnetic resonance imaging (MRI) of the left hand, there was peripherally enhancing tenosynovitis involving the extensor compartment (Fig. 2). There was no evidence of underlying septic arthritis or osteomyelitis.
Intraoperative photograph showing inflammation in the fourth
extensor compartment and tenosynovitis.
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Ch1.F3
Upon exposing the extensor mechanism of the left hand, inflammation was noted in the fourth extensor compartment with edema and fluid but no frank pus (Fig. 3).
Axial T2-weighted fat-suppressed image (a) and corresponding
post-contrast T1-weighted fat-suppressed image at the level of the distal
forearm (b) obtained 12 months later after repeat surgical debridement procedures and
antifungal therapy demonstrate an intermediate T2-signalling, hypoenhancing
inflammatory nodule (white arrows) overlying the common extensor tendons.
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Ch1.F4
Three months following the initial left hand debridement, the patient presented with a new nodule and a 1.2 cm fluid collection on the third MCP joint of the left hand; MRI was suggestive of worsening tenosynovitis (Fig. 4).
Multiple ulcerative violaceous edematous nodules on the dorsal
hand in a patient with dermatomyositis and histoplasmosis-associated
extensor tenosynovitis.
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Ch1.F5
Soon after completely discontinuing steroids at 6 months of antifungal therapy, the patient presented with weeping, nodular, white lesions along the surgical incision marks (Fig. 5).
Hematoxylin and eosin (H&E) stain of skin punch biopsy demonstrates necrotizing
granulomatous inflammation ( magnification).
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Ch1.F6
Dermatologic punch biopsy of one of these lesions revealed necrotizing granulomatous inflammation (Fig. 6) with small, budding yeasts seen on Grocott's methenamine silver (GMS) stain, consistent with Histoplasma (Fig. 7).
Residual violaceous indurated scars on the dorsal hand in regions
of previous suppurative and ulcerative lesions of histoplasmosis-associated
extensor tenosynovitis in a patient with dermatomyositis. A single
suppurative lesion remained on the medial dorsal hand.
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Ch1.F8
At the time of the patient's last follow-up, the suppurative and ulcerative lesions on the left dorsal hand, as well as the edema, had mainly resolved, leaving indurated violaceous scars (Fig. 8).