PMC4664794_01
Initial lesion: erythematous nodule on right shin.
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Erythematous tender nodules were noticed on bilateral lower extremities (Figure 1).
Ultrasound upper abdomen. Multiple hypoechoic tiny lesions on both lobes, few of them cystic in appearance.
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An upper abdominal ultrasound showed hypoechoic, cystic lesions scattered across both lobes of the liver (Figure 2).
CT abdomen with contrast: multiple hypoattenuating lesions in the liver.
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A subsequent CT scan of the abdomen with contrast showed multiple oval hypoattenuating lesions in both lobes of the liver (Figure 3).
Liver biopsy. Cholestasis with multiple large areas of necrosis palisaded by epitheloid cells with associated granulomatous inflammation.
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Ulceration in the nodule with erythema and discharge.
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Leg lesions were becoming worse with central necrosis and purulent discharge (Figures 5 and 6).
Ulceration progressing to central necrosis.
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Leg lesions were becoming worse with central necrosis and purulent discharge (Figures 5 and 6).
Skin biopsy. Vasculitis involving the superficial and deep dermis showing fibrinoid necrosis of vessel wall with granuloma formation, neutrophilic infiltrate, and nuclear debris.
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Pathological examination of frozen sections revealed surface ulceration with fibrinoid necrosis and vasculitis involving superficial and deep dermal vessels along with granuloma formation, neutrophilic infiltration, and debris (Figure 7).
After treatment with 7 weeks of prednisone and azathioprine.
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After seven weeks on prednisone and six weeks of azathioprine her lesions had healed almost completely (Figure 8).