A 17-Year-Old African American female was referred for the evaluation of arthritis and lower extremity rash. Her medical history was remarkable for polyarticular juvenile rheumatoid arthritis diagnosed at age 2 years. A red raised rash developed involving both lower extremities when the patient was 4 years old. In addition, she was recently examined for bilateral pulmonary infiltrates (Figure 1, left).
On physical examination she was noted to have severe symmetric polyarthritis with involvement of the large and small joints. Flexion contractures involving the elbows and proximal interphalangeal joints of both hands were seen. In addition to the deforming polyarthritis, she had bilateral lower extremity edema below the knees and a purplish papular scaly rash (Figure 2). Results of the rest of her physical examination were unremarkable. Ophthalmologic evaluation revealed the presence of severe iritis in both eyes.
Laboratory values were as follows: hemoglobin, 111 g/L; white blood cells, 8.0×09