case_images: PMC3565908_01
case_images: Photograph of the right ankle and foot showing an erythematous papular rash with ulcerations on presentation.
case_images: 1752-1947-7-20-1.jpg
case_images: PMC3565908_01_1752-1947-7-20-1.jpg
case_images: F1
case_images: An examination revealed hypertension (blood pressure 160/70mmHg), a pansystolic murmur, an aphthous ulcer at the base of her tongue and a rash over her right ankle and foot (Figure  1). The associated skin rash (Figures  1 and 2) did not have a clear role in her presentation but was initially thought to be early Sweet's syndrome associated with a drug-associated vasculitis.
case_images: Photomicrograph of the skin biopsy with a hematoxylin and eosin stain x100 showing a heavy neutrophil infiltrate involving the full thickness of the dermis with no evidence of a leucocytoclastic vasculitis.
case_images: 1752-1947-7-20-2.jpg
case_images: PMC3565908_01_1752-1947-7-20-2.jpg
case_images: F2
case_images: The associated skin rash (Figures  1 and 2) did not have a clear role in her presentation but was initially thought to be early Sweet's syndrome associated with a drug-associated vasculitis.
case_images: Photomicrograph of the renal biopsy with a hematoxylin and eosin stain x400 magnification showing a pauci-immune, focal necrotizing glomerulonephritis with one small crescent consistent with anti-neutrophil cytoplasmic antibody-associated vasculitis. Red cell casts are present. There is an interstitial infiltrate of lymphocytes, macrophages and eosinophils which involves some tubules. Immunofluorescence staining revealed mild mesangial deposition of immunoglobulin M and traces of mesangial C3.
case_images: 1752-1947-7-20-3.jpg
case_images: PMC3565908_01_1752-1947-7-20-3.jpg
case_images: F3
case_images: Hydralazine was withdrawn and the patient underwent a transjugular renal biopsy to confirm the diagnosis (Figure  3).