Necrotizing Cutaneous Vasculitis in a Patient With Infective Endocarditis and Severe Rheumatoid Arthritis

A 68-year-old woman with fever, chills, asthenia, night sweats, arthralgia, weight loss, and necrotizing skin ulcers on the body and lower extremities was admitted to our department.  She had been followed for rheumatoid arthritis (RA) for over 20 years, and her rheumatoid factor (RF) level was very high at admission. A month ago, a temporary pacemaker was applied to the patient due to drug-induced bradyarrhytmia, but the pacemaker’s lead  fractured and remained inside the right ventricle while it was removed. Revealing the vegetations on the fractured lead and tricuspid valve by echocardiography and methicillin- resistant coagulase-negative Staphylococcus aureus in separate blood cultures, the  two major criteria for the diagnosis of infective endocarditis (IE) was confirmed to commence treatment of IE. The biopsy specimen from the skin ulcers revealed cutaneous vasculitis. Vasculitis is a serious complication of rheumatoid arthritis (RA) that develops in a minority of patients with this disease, and it is not uncommon in patients with IE. The diagnosis of rheumatoid vasculitis was confirmed by the history, clinical and laboratory findings of our patient. Methylprednisolon 500 mg intravenous bolus followed by 40 mg PO daily was administered. In spite of all taken measures the patient died of severe sepsis on the 50th day of her admission. In this case the differential diagnosis of cutaneous vasculitis in a patient with IE and severe RA is emphasized. doi:10.4021/jmc591w