An 11-year-old male patient, with no relevant health history, who consulted the Austral University Hospital for pain and swelling of the left foot, with 15 days of evolution.
The patient was in good general condition, normotensive and afflicted. Physical examination revealed an erythematous and painful plaque on the left sole.
Due to suspicion of an infectious process, hospitalization was decided.
Laboratory tests showed mild leukocytosis and high erythrosedimentation; two hemocultives and puncture for healthy skin, all negative.
Radiographs, scintigraphy and magnetic resonance imaging of the affected limb were also requested, ruling out bone involvement.
Ibuprofen 400 mg every 6 h and cephalothin 100 mg/kg/day every 6 h associated with gentamicin 5 mg/kg/day for 3 days were indicated.
Due to unfavorable evolution, clindamycin was prescribed, 40 mg/kg/day every 8 h associated with rifampicin, 20 mg/kg/day every 12 h.
On the sixth day of hospitalization, due to the appearance of nodules in the upper limbs, fever and arthralgia of ankles and wrists, an inter-consultation with the Pathological Service was carried out.
On that occasion, on physical examination, multiple painful erythematous nodules measuring 1-2 cm were observed, grouped into upper and lower limbs, other nodules posterior erythematous purpura of the right ankle, with a longer evolution in the internal arch of the foot.
No ulcerations or other cutaneous signs were observed.
With presumptive diagnoses of cutaneous panarteritis nodosa (PANC), atypical erythema nodosum or other pan HBVPT lymphocytes 61% VHCV, HBsAg seropositivity:
Culture of fauces: negative.
PPD 2 UT was nonreactive.
In addition, studies were performed to rule out systemic involvement: hepatogram, urea, creatinine, ionogram, blood gases, urine analysis, eye fundus, ocular pressure, Doppler echocardiography, chest X-ray, abdominal ultrasound and Doppler of the limbs.
The histopathological study of the biopsy of a nodule of the lower limb showed at the level of interobserver numerous hypodermic caliber and, in hypodermis, neutrophilic inflammatory involvement and fibrinoid material in the lumen walls with small eosinophils.
These histopathological findings allow us to arrive at the diagnosis of vasculitis of small dermohypodermic vessels and small caliber arteries.
Due to the cutaneous manifestations and the results of the studies, the diagnosis of NCCP was confirmed.
It was decided to suspend the antibiotic and start treatment with meprednisone 1 mg/kg/day, total daily dose of 40 mg and prophylactic penicillin, due to the history of a positive ASTO.
There was partial improvement at the beginning of treatment, but due to the persistence of lesions, fever and arthralgias, the dose of meprednisone was increased to 60 mg/day after eight days with favorable response and no evidence of rebound.
