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Abstract

We present a case of a 39-year-old female who initially presented with necrotizing small vessel vasculitis of the uterus. Shortly after, she was diagnosed with active tuberculosis (TB) and started on RIPE therapy (rifampin, isoniazid, pyrazinamide, and ethambutol). She developed a constellation of clinical symptoms, and laboratory work up revealed pancytopenia, low C3 and C4, +ds-DNA, +ANA 1:320, and +pANCA >1:640. Systemic lupus erythematosus (SLE) and vasculitis were considered as a cause for her clinical issues. The patient then presented to dermatology with a progressive facial rash. The eruption initially involved the nose and cheeks but gradually spread across the face to include vesicular features. The clinical differential diagnosis included SLE, vasculitis, or an eruption to TB medications. Clinically, the patient had violaceous plaques in a malar distribution, across the brows, and in conchal bowls. She also had vesicles with necrotic black crusts on the left side of the chin. Given the suspicion for varicella zoster virus on the chin, the patient was started on valacyclovir, and a biopsy was done for confirmation. Biopsy of the chin demonstrated vacuolar interface dermatitis with viral cytopathic changes and Varicella Zoster Virus (VZV)-positive nuclei. A biopsy from the antihelix revealed a lichenoid interface dermatitis with follicular plugging, consistent with discoid lupus erythematosus. Following these results, the patient was also started on prednisone, leading to marked clinical improvement. This case underscores the diagnostic complexity of cutaneous eruptions in immunocompromised patients with overlapping autoimmune and infectious conditions, and the role dermatopathology can play in differentiating