MKSAP: 21-year-old woman with a rash in the lower extremities

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 21-year-old woman is evaluated for a 3-week history of painful nodules and a rash in the lower extremities, along with pain and swelling of the wrists, knees, and ankles. She reports a low-grade fever and a 2.7-kg (6.0-lb) weight loss since the onset of symptoms. She has taken naproxen with some relief. History is significant for gastroesophageal reflux disease and acne. Medications are over-the-counter famotidine as needed and minocycline. On physical examination, temperature is 38.2 °C (100.8 °F), blood pressure is 110/60 mm Hg, pulse rate is 92/min, and respiration rate is 16/min. BMI is 24. Mild swelling of the wrists, knees, and ankles is noted. There are scattered 1- to 2-cm painful erythematous nodules as well as livedo reticularis in the lower extremities beginning at the thighs. The remainder of the examination is normal. Laboratory studies: Antinuclear antibodies Positive (titer: 1:320) Anti–double-stranded DNA antibodies Negative Anti-Smith antibodies Negative Anti-U1-ribonucleoprotein antibodies Negative Anti-Ro/SSA antibodies Negative Anti-La/SSB antibodies Negative Antihistone antibodies Negative ANCA Positive (titer: 1:320) in a perinuclear pattern; negative for myeloperoxidase Urinalysis Normal Chest radiograph is normal. Which of the following is the most appropriate next step in management? A: Start azathioprine B: Star...
Source: Kevin, M.D. - Medical Weblog - Category: Journals (General) Authors: Tags: Conditions Rheumatology Source Type: blogs