A 45 year old man presented to us with multiple large joint pains of 8 days duration followed by development of multiple painful red raised lesions over both palms and back of both legs associated with redness of eyes.
There was no history of upper respiratory tract infection, gastro-intestinal disturbances or fever. There was no past history of diabetes mellitus, hypertension or tuberculosis.
On examination multiple tender erythematous papules and firm nodules were present on both palms and both legs. [Figure 1] Bilateral scleral congestion was present. [Figure 2]. Both knee and ankle joints were swollen and tender with restricted movements.
There was no clinical evidence of Hansen's disease and no acid fast bacilli were detected by slit skin smear using modified Ziehl Nielsen technique.
Based on history and clinical examination a tentative diagnosis of Erythema elevatum diutinum (EED) was made which was substantiated further by a skin biopsy from a representative lesion showing a hyperkeratotic, acanthotic epidermis overlying dermis containing perivascular mixed inflammatory infiltrate comprising lymphocytes, neutrophils along with nuclear dust and fibrinoid necrosis of the vessel wall and extravasation of RBCs. There was presence of focal areas of basophilic collagen [Figures 3 and 4].
All hematological and biochemical tests were within normal limits except raised total leukocyte count and ESR. Other immunological and serological tests were negative. Ophthalmological opinion was sought and the clinical diagnosis of scleritis was confirmed.
Patient was started on 100 mg dapsone per day along with NSAIDS, to which there was a dramatic response with clearance of cutaneous, ocular and joint lesions within a couple of weeks' time and the patient was lost to follow-up after 3 months, by which time his lesions had considerably cleared up and he was advised to stop Dapsone.