Intended for healthcare professionals

Endgames Spot Diagnosis

Fever, arthritis, and painful skin nodules

BMJ 2021; 374 doi: https://doi.org/10.1136/bmj.n1956 (Published 16 September 2021) Cite this as: BMJ 2021;374:n1956
  1. Yu-Pei Lin, attending physician1,
  2. Chi-Sheng Chiou, attending physician2
  1. 1Division of Endocrinology and Metabolism, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
  2. 2Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
  1. Correspondence to C-S Chiou 53guyton{at}gmail.com

A woman in her 40s presented to the emergency department with a 3 day history of fever (~39°C), bilateral swelling of the ankle joints, and multiple severely painful skin nodules on her shins (fig 1). She had applied a topical steroid to the leg lesions but this had not helped.

Fig 1

Multiple severely painful skin nodules on the shins

For the previous five years she had recurrent oral ulcerations (more than four episodes per year) and several instances of vulval ulceration. During this time, she had tried stress relief for the oral ulcers and topical antifungal, antiviral, and steroid ointments three times a day for two weeks for the vulval lesions. However, response to these treatments was poor and the ulcerations still occurred intermittently.

On examination, the erythematous shin nodules measured 1-2 cm in diameter and were firm and severely …

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