Patient has painful papules on both sides of hands. Please provide diagnosis.

Question

Hello doctor,

The patient is a 12-year-old female. One month ago, she presented with drenching sweating and cold feeling with cold hands. Two weeks later, the skin of the hands became erythematous and blanched on pressure. Then, they gave her a measles vaccine in the school. Two days later, she developed painful papules on both sides of her fingers and palms. All these symptoms are associated with malaise and generalized muscle pain. Their blood pressure is 130/90 and their pulse is 130 per minute. Endocrine investigation, echo, CXR, abdominal us, abdominal CT, autoimmune Ab all negative. IFAT for brucellosis negative. No sign of arthritis, only arthralgia. Now she takes Prednisolone 5 mg Chloroquine tablet and Lyrica capsule. The rash is improving, but malaise and myalgia with arthralgia are still present. I would greatly appreciate it if you can provide me with your diagnosis regarding this case as our local physicians have confused us with multiple diagnoses. Any information about the disease is greatly appreciated. Is it life-threatening? Kindly advise on what you find necessary. The attached pictures are the patient's medical test results as well as some photos of her hands.

Answer 1

Hello,

Welcome to icliniq.com.

I went through your post (attachment removed to protect patient identity). The significant problems mentioned in the post are:

Palmar erythema.
Leucocytosis with TLC 1400.
Thrombocytosis.
Low complement C3.

All these could be manifestations of vasculitis. However, I have not seen her LDH (lactate dehydrogenase) and CPK (creatine phosphokinase) levels documented. The possibility of chronic infection is there. So, hepatitis serology needs to be done which can also cause similar symptoms. I will treat this patient who has hypocomplementemia vasculitis after doing a nail foldcapillaroscopy and skin biopsy. I suggest giving her a Prednisolone dose of 0.25 mg/kg per day for two weeks and simultaneously doing the investigations as mentioned. Consult a specialist doctor, discuss with him or her, and start the medicines with their consent.

Thank you.