Issue: 2019 > January > photo quiz

All good things come in threes

J.W.H.J. Geerts, J.E. Stalenhoef, D.J. van Westerloo
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A 67-year-old female visited the outpatient clinic because of a low-grade fever and abdominal pain. Her medical history was relevant for undifferentiated connective tissue disease (UCTD) and ureteropelvic junction obstruction. At the time, no diagnosis was made and she was sent home. However, after three days, she was admitted to our hospital because of fever and suspected sepsis. Upon admission, she was hemodynamically stable and laboratory investigation revealed a leucocytosis of 9 x109/l, an elevated C-reactive protein (CRP) of 163 mg/l and a preserved kidney function with a creatinine of 75 µmol/l. Urinalysis revealed pyuria and ultrasound was consistent with hydronephrosis. She was diagnosed with sepsis due to pyonefrosis, and drainage of the pyelum was secured with a nephrostomy and she was started on Ceftazidime. Unfortunately, she developed an anaphylactic reaction, including facial swelling and angioedema for which she was admitted to the ICU and intubated. She was treated with antihistamines, steroids and adrenalin and Ceftazidime was discontinued. Amongst her medication were hydroxychloroquine and low-dose prednisone.

During her stay in intensive care, three dissimilar skin lesions were observed as shown in figure 1 (1A, ankle; 1B, fingers and 1C, buttocks). The dermatologist was consulted and a biopsy was performed from the lesion on the pelvis (figure 1C). Cryoglobulins were only slightly elevated. Three separate diagnoses were considered.


See page 33 for the answer to this photo quiz.