A 52-Year-Old Man Comes to the Physician with Leg Ulcers

question 514

Multiple Choice

A 52-year-old man comes to the physician with leg ulcers.  Two months ago a small ulcer appeared on the right medial malleolus, and now there are 2 additional ulcers on both legs.  He was diagnosed with seropositive rheumatoid arthritis 15 years ago and has been on oral prednisone, sulfasalazine, and hydroxychloroquine since then.  Eight years ago methotrexate was discontinued due to liver toxicity.  Five years ago he received etanercept for a few months, but this was discontinued due to frequent sinus infections.
The patient's other medical problems include gastritis, type 2 diabetes mellitus, and colon polyps.  He is a cattle farmer and does not use tobacco, alcohol, or illicit drugs.
He is afebrile and vital signs are normal.  Skin examination is notable for several nodules on the extensor surface of the elbows.  There are 3 shallow ulcers on both legs in various stages of healing.  Heart and lung sounds are normal.  Spleen is palpable 2 cm below the left costal margin.  There are rheumatoid deformities of both hands and feet with decreased range of motion in wrists, elbows, and ankle joints.  Neurologic examination is normal.
Laboratory results are as follows:
Which of the following conditions is the most likely diagnosis?

• A)Cutaneous polyarteritis nodosa
• B)Felty's syndrome
• C)Necrobiosis lipoidica diabeticorum
• D)Pyoderma gangrenosum
• E)Sweet's syndrome

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Definitions:

Joint Ownership

A form of property ownership in which two or more parties share ownership rights simultaneously.

Limited Partner

In a limited partnership, a partner who contributes capital to the partnership but has no right to participate in its management and has no liability for partnership debts beyond the amount of her or his investment.

Dissolution

The process of officially ending or dissolving a business, partnership, or marriage, along with the settling of its affairs.

Limited Partnership

A business structure where one or more partners are liable only up to the amount of their investments, while at least one other partner has unlimited liability.