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case_images: (A) Foot rash, partially ulcerated and scabbed. (B, C) Before treatment, the HRCT scan of the chest showed multiple patchy and nodular lesions with unclear boundaries, indicating high-density shadows in both lungs. And multiple enlarged lymph nodes were observed in the mediastinum and bilateral hilar regions. (D) Before treatment, the CT plain scan of the paranasal sinuses revealed a notable thickening of the mucosa in the bilateral maxillary, ethmoid, sphenoid, and frontal sinuses. (E) Before treatment, the MRI scan of the brain showed multiple abnormal signal shadows in the bilateral cerebral cortex. (F) Before treatment, the MRA revealed moderate to severe stenosis in the middle cerebral artery segment M2 of the left middle cerebral artery.
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case_images: Spotted papules were visible on her hands and feet, which were partially ulcerated and scabbed, accompanied by pain ( Figure 1A ). The high-resolution chest computed tomography (HRCT) imaging revealed multiple patchy and nodular lesions with unclear boundaries, indicating high-density shadows in both lungs ( Figure 1B ). Additionally, multiple enlarged lymph nodes were observed in the mediastinum and bilateral hilar regions ( Figure 1C ), and a small amount of pleural effusion was present on the right side. The CT plain scan of the paranasal sinuses revealed a notable thickening of the mucosa in the bilateral maxillary, ethmoid, sphenoid, and frontal sinuses ( Figure 1D ). MRI scan of the brain showed multiple FLAIR hyperintensities in the bilateral cerebral cortex ( Figure 1E ). The magnetic resonance angiography (MRA) revealed moderate to severe stenosis in the middle cerebral artery segment M2 of the left middle cerebral artery ( Figure 1F ), while the magnetic resonance venography (MRV) showed no significant abnormalities.
case_images: (A) Before treatment, the skin pathological examination of the left ankle showed a reticulated pattern of hyperkeratosis, accompanied by necrosis in the central epidermis. In the superficial and middle layers of the dermis, fibrinoid necrosis is observed in the blood vessel walls, concurrent with neutrophil infiltration. Numerous neutrophils and eosinophils are visible infiltrating the areas surrounding the blood vessels, while erythrocyte extravasation and nuclear dust are also apparent. Notably, no distinct granulomatous structure is evident, and the overall changes are indicative of leukocytoclastic vasculitis. (B, C) Before treatment, the pathological examination of the lung tissue biopsy indicated the presence of chronic suppurative inflammation, accompanied by fibrous tissue proliferation and fibrosis.
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case_images: Notably, no distinct granulomatous structure is evident, and the overall changes are indicative of leukocytoclastic vasculitis ( Figure 2A ). The pathological examination of the lung tissue biopsy indicated the presence of chronic suppurative inflammation, accompanied by fibrous tissue proliferation and fibrosis ( Figures 2B, C ).
case_images: (A, B) After treatment, the chest CT scans revealed significant improvement in lung inflammation and no obvious enlarged lymph nodes were seen in the mediastinum and bilateral hilar. (C) After treatment, the cranial MRI showed a reduction in the abnormal signal intensity in the bilateral cerebral cortex compared to the previous scan. (D) After treatment, there were no markedly abnormal findings in cranial MRA.
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case_images: Chest CT scans revealed significant improvement in lung inflammation ( Figures 3A, B ), pulmonary function test showed mild ventilation-diffusion dysfunction. And the cranial MRI showed a reduction in the abnormal signal intensity in the bilateral cerebral cortex compared to the previous scan ( Figure 3C ) while the cranial MRA was unremarkable ( Figure 3D ).
case_images: PMC11133702_02