A 59-year-old woman who was diagnosed with rheumatoid arthritis now has a rash and fingertip ulcer. Wind list is finalized.

Don't want to miss Jiemei's push? Poke the blue word "medical rheumatism and nephropathy channel" to pay attention to us and click the "··" menu in the upper right corner, and select "set as star" to challenge the final decision of this week's wind list. A 59 year old woman once diagnosed with rheumatoid arthritis (RA), during which she received intermittent treatment, followed by rashes, ulcers and even gangrene.as a rheumatologist, RA patients are not uncommon, but similar cases are not common.let's challenge the final conclusion of this week's wind list ~ the case is a 59 year old female with previous diagnosis of "seropositive RA, type 2 diabetes, hypothyroidism and fibromyalgia syndrome".when the patient first diagnosed RA, physical examination showed that the patient had multiple subcutaneous nodules, involving the upper limbs, including the elbow, forearm and multiple metacarpophalangeal joints (see Figure 1). No rash, ecchymosis and ecchymosis were found.it can be seen from the physical examination in Fig. 1 that patients with rheumatoid nodules have been treated with various anti rheumatic drugs (DMARDs), including methotrexate, hydroxychloroquine and sulfasalazine.the patient is currently receiving etanercept, leflunomide and prednisone.however, patients often stop taking etanercept on their own and have not been reexamined regularly.in addition, the patient had a long history of smoking, with an average of 20 cigarettes / day.in the next two years, the number of rheumatoid nodules increased, and multiple nodule lesions were found in the limbs.rashes on the elbow and forearm began to appear (Fig. 2), accompanied by pruritus and pain.the scope of the rash gradually expanded, involving the lower extremities, including the skin of the lower leg and plantar.in Figure 2, erythema on the forearm was found again. However, the patient still did not insist on taking RA related drugs.after that, ulcers appeared on the fingertip and lower limb skin of the patient (see Figure 3). Vascular surgeons considered "dry gangrene" and treated it, and did not use DMARDs temporarily.however, due to the morning stiffness and pain symptoms of multiple joints and RA activity, prednisone was used.in Figure 3, when the wound of patients with finger tip skin ulcer began to heal, the doctor repeatedly suggested that DMARDs should be used again.however, the patient did not add DMARDs as prescribed and did not have regular review.the patient's left plantar skin lesions worsened, and he was hospitalized in the emergency department due to fever.laboratory tests showed that: rheumatoid factor positive, ESR: 91 mm / h, C-reactive protein: 17.1 mg / L, white blood cell count: 13.1 × 109 / L, hemoglobin: 9.6 g / dl, hematocrit: 30.8%.the patients were hospitalized for pathological biopsy of skin lesions to further clarify the diagnosis and treatment.this is the story of the case. I believe you can find out the truth behind the incident.correct answer: rheumatoid vasculitis.the biopsy of this patient showed diabetic skin lesions and venous insufficiency, as well as leukocyte ruptured vasculitis with thrombosis and necrosis.the patient initially presented with a rash, which may be due to vasculitis of small superficial vessels, but the patient's condition was poorly controlled, resulting in osteomyelitis and hospitalization.the patient was treated with antibiotics intravenously after hospitalization. Rituximab and leflunomide were used in the treatment of RA, and prednisone was used intermittently to control the disease.in the following year, the patient underwent multiple wound debridement and surgical evaluation, and finally amputated under the knee.conclusion: the outcome of this case is not optimistic, which reminds us of the importance of drug compliance for RA patients. Br / >it is helpful for patients to improve the prognosis as a clinician.combined with this case, let's learn about RA vasculitis ~ RA is a systemic autoimmune disease characterized by erosive arthritis.the disease is more common in women, and the ratio of male to female is 1:3.the main manifestations of RA are symmetrical, persistent joint swelling and pain, often accompanied by morning stiffness.in addition to joint symptoms, there can also be subcutaneous nodules, known as rheumatoid nodules.other tissues and organs outside the joint may be involved in RA patients. Studies have shown that the incidence of extraarticular involvement in RA patients is 17.8% ~ 47.5%, and the involved tissues and organs include skin, lung, heart, nervous system, eye, blood and kidney.RA patients with extraarticular manifestations have more complications and higher mortality. early diagnosis and treatment of RA, the condition is usually well controlled. if the patient's compliance is poor or without treatment, such a patient is more likely to have extraarticular manifestations. clinicians should have a comprehensive understanding of the patient's condition and reasonably formulate or adjust the medication regimen. rheumatoid vasculitis is a type of vasculitis associated with RA, which can lead to rash, gangrene of the fingertip and leg ulcers. necrosis and neuropathy of the fingers and toes are serious manifestations of vasculitis, and the typical pathological change is necrotizing vasculitis. the pathological process of vasculitis involves the binding of autoantibodies and immune complexes with small and medium-sized vascular endothelial cells. type III hypersensitivity is due to endothelial cells having autoantibody binding receptors; once activated, a series of events leading to inflammatory reactions will occur, including plasma extravasation, leukocyte aggregation and activation of coagulation cascade reaction. cytotoxic substances released by leukocytes further damage lumen endothelial cells, resulting in vascular lesions and rash. rheumatoid vasculitis is usually diagnosed by clinical manifestations. The gold standard of histology is transmural infiltration and fibrous necrosis of vascular wall. leukocyte rupture is also one of the diagnostic criteria in skin biopsy criteria. has a clinical incidence rate of 1%~5%, and is more common in serological positive patients with a duration of more than 10 years. The study shows that the 5 year mortality rate can reach 30%~50%, and over 50% of patients suffer from ischemic ulcers, especially in the distal part of the lower extremities. however, with the progress of RA treatment, including the use of biological DMARDs, the current mortality rate may be reduced. in addition, rheumatoid vasculitis often occurs in smokers, especially in RA patients with rheumatoid nodules and more than 10 years of disease. clinically, for RA smoking patients, encourage them to quit smoking to prevent the progression of vasculitis. this patient developed extensive vasculitis, and was treated with immunosuppressive agents and glucocorticoids to control the progression of the disease. Moreover, studies have confirmed that biological agents can reduce vascular inflammation related to endothelial dysfunction, which is a potential therapeutic drug. References: [1] Victoria M.F. mank, Jefferson R. Roberts. A 59 year old woman with a painful rush and fingertip uloperations - Medscape - Oct 11, [2] Chinese society of rheumatology. Chinese Journal of internal medicine (4): 242-251. [3] Chinese society of rheumatology. Guidelines for diagnosis and treatment of rheumatoid arthritis [J]. Chinese Journal of Rheumatology, 2010 (4): 265-270. [4] Zhou Lamei, Jiang Xuefeng, Lu Lijun. Analysis of 4 cases of rheumatoid vasculitis [J]. Journal of Liaoning Medical College, 2014 (4): 103-104