A 59-Year-Old Woman With Chronic Skin Lesions of the Leg - QUIZ

Figure 1. Progressive atrophic and erythematous skin lesions on the left leg.

Figure 3. Asymptomatic skin rash on the back of the patient’s left ankle in July 2008.

Figure 2. Erythema with mild atrophy of the left foot.

A 59-year-old woman, a retired school director with no particular medical history, sought consultation because of chronic skin lesions on her left leg (Figures 1 and 2), which had been present for several months. Erythematous and minor atrophic lesions of the skin were seen. No infiltration was noted, and no other local symptom mentioned. The patient did describe pain in several joints. The physical examination found no other abnormalities. The patient also mentioned a history of a skin rash 3 years earlier, on the left ankle, which had appeared after a walk in a forest in southern France. A photograph she had taken then showed a large erythematous ring, which subsequently spread to the entire leg (Figure 3). No macular lesion was seen, and no pain at the time was reported. Laboratory analysis revealed a white blood cell count of 4420 cells/µL. Her C-reactive protein level was 3 mg/L (reference, <5 mg/L), and her fibrinogen level was 3 g/L (reference range, 2–4 g/L). Her liver enzyme and total complement activity levels were normal. The test for rheumatoid factor test was negative, but that for antinuclear antibodies was positive (1:200), with no specificity. The skin biopsy of a nonatrophic area showed cutaneous lymphoplasmacytic infiltration of interstitial tissue. 

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Clinical Infectious Diseases 2013;57(12):1751

DOI: 10.1093/cid/cit661