case_images: PMC10634479_01
case_images: (a) Extensive ulceronecrotic lesions with haemorrhagic crusting bilaterally. Intake pustules are visible at the periphery. (b) Persistent cutaneous ulceration 2 months after starting therapy. (c) Complete healing of skin lesions 1 month after starting adjuvant tofacitinib.
case_images: acmi-5-460.v3-g001.jpg
case_images: PMC10634479_01_acmi-5-460.v3-g001.jpg
case_images: F1
case_images: On examination the patient had multiple well-defined punched out ulcers of varying sizes with violaceous margins and necrotic haemorrhagic slough, present predominantly over both extremities (Fig. 1a). The patient reported mild improvements after the first dose of adalimumab but presented with increased skin lesions and systemic complaints (fever and joint pain) after the second dose (Fig. 1b). One month after administration of tofacitinib the patient reported marked healing of the skin ulceration and cessation of new lesions (Fig. 1c).
case_images: Findings of biopsy from margins of ulcers and lymph nodes. (a) Infiltrates following neuro-vascular bundles; haematoxylin and eosin (H&E) staining, 40x. (b) Fibrinoid degeneration of vessel walls; H&E staining, 100x. (c) Foamy histiocytes with admixed neutrophils; H&E staining, 400x. (d) Presence of solid and fragmented lepra bacilli; Fite-Faraco staining, 1000x. (e) Infiltration of foamy histiocytes in a lymph node; H&E staining, 100x. (f) Presence of lepra bacilli in a lymph node; Fite-Faraco staining, 1000x.
case_images: acmi-5-460.v3-g002.jpg
case_images: PMC10634479_01_acmi-5-460.v3-g002.jpg
case_images: F2
case_images: Punch biopsy of the skin from margins of ulcers demonstrated infiltrates of foamy histiocytes and lymphocytes following neurovascular bundles, admixed with neutrophils and signs of vasculitis (Fig. 2a-c). Fite-Faraco staining revealed fragmented and granular acid fast bacilli (Fig. 2d). Biopsy of inguinal lymph nodes showed infiltration of foamy histiocytes and presence of acid fast bacilli (Fig. 2e, f).