REPORT OF A CASE
A 52-year-old black woman with rheumatoid arthritis presented with a 9-month history of recurrent painful macules and papules on the extremities. Her medical history was significant for chronic obstructive lung disease, hypertension, and insulin-dependent diabetes, all of which were well controlled. Her medications included prednisone, 5 mg orally per day, insulin, nizatidine, ibuprofen, hydrochlorothiazide, and several inhalers. She denied having fevers, abdominal pain, hematuria, or dark stools.On physical examination she had multiple tender, erythematous macules and palpable purpura on all 4 extremities. Older lesions had lost their erythema and residual hyperpigmented macules remained. Multiple subcutaneous rheumatoid nodules were present around both elbows. Several joints on both hands were indurated and warm; however, the erythematous macules and papules spared her hands.Histopathologic examination revealed a predominantly perivascular infiltrate consisting of lymphocytes, histiocytes, eosinophils, and neutrophils. Neutrophils in the capillary walls, endothelial cell swelling, extravasated erythrocytes, and