A 46-year-old African American woman was admitted to the hospital with complaints of multiple joint pains associated with skin lesions, which had lasted for 3 weeks. The pains were in her right ankle, left wrist, both great toes, and right thumb. Further systems review revealed that the patient had experienced a fever of 102°F, diarrhea (at times bloody), chills, nausea, and decreased appetite for 5 days along with low back pain for 1 week.
Her medical history was significant for hypertension, hypothyroidism, chronic gastrointestinal symptoms attributed to irritable bowel disease for the past 2 years, and intermittent asymmetrical oligoarthritis for 1 year that had responded to episodic treatment with prednisone. She also had 2 episodes of iritis in the previous 4 years responsive to topical corticosteroids.
On exam she looked sick, was febrile, and had skin lesions in vaginal, axillary, perianal, foot, and thigh areas (FIGURES 1 AND 2). The lesions were 5 to 40 mm in size, exquisitely tender, bullous, pustular, and formed violaceous ulcers with scanty purulent-looking discharge. Her ankle exam was significant for swelling, redness, warmth, tenderness and severe pain on passive and active movements (FIGURE 3). Results of an examination of her spine was within normal limits. The remainder of her physical exam also showed normal results.
FIGURE 1
Ulcer on thigh
FIGURE 2
Lesion on foot
FIGURE 3
Swollen ankle joint
What is your diagnosis?