A Woman With Painful Digital Ulcers

A 66-year-oldwoman with a history of hypertension, type 2 diabetes, and chronic hepatitis-Btreated with tenofovir presented to the emergency department for evaluation of digital erythema and painful finger ulcers, which developed 6 months prior but which had increased in number and become more painful in the past several weeks. She also reported dyspnea on exertion, which developed 6 months prior to presentation. Onphysical examination, her peripheral oxygen saturation was 95% on room air. Auscultation of her lungs revealed crackles at the bases bilaterally. She had normal strength throughout all muscle groups and full range of motion in the joints of her hands. The palmar surfaces of her hands revealed livedo racemosa, erythema, and retiform purpura; ulcers overlying her phalangeal joint creases and fingertips; and scale and fissures on several digits (Figure). On the dorsal surfaces there was a large ulcer on the right second metacarpophalangeal joint and erythematous papules over several metacarpophalangeal joints. Ulcers were also noted on her elbows. Laboratory testing showed a hemoglobin level of 10.5 g/dL and normal creatine kinase level. The patient was admitted to the hospital for pain management and expedited workup of her progressive finger ulcerations.

Automated summary

A 66-year-old woman with a history of hypertension, type 2 diabetes, and chronic hepatitis-B presented to the emergency department for evaluation of digital erythema and painful finger ulcers. Physical examination revealed livedo racemosa, erythema, and retiform purpura on the palmar surfaces of her hands, ulcers on her phalangeal joint creases and fingertips, and large ulcer and erythematous papules on the dorsal surfaces. Hemoglobin level 10.5 g/dL with normal creatine kinase level. Admission for pain management and further workup was necessary.