A fourteen-year-old girl presented with history of fever, painful subcutaneous nodules with ulcerations in both the lower limbs for two months, and digital gangrene of the right index finger for one-month duration. There was no history of purpura, Raynaud's phenomenon, recurrent oral ulcers, hair loss or malar rash. The history of throat pain, jaundice or past tuberculosis was negative. The general physical examination showed normal vitals with multiple subcutaneous ulcers predominantly distributed over both the lower limbs [Figures 1a and b] and bluish black discoloration of distal phalanx of the index finger. The laboratory investigations are shown in Table 1. The renal function and liver function tests were normal. The peripheral smear showed elevated total count and Anti-streptolysin O (ASLO) titer was elevated. The throat and urine culture showed no growth of bacteria. The ultrasonography of the abdomen and echocardiography of the heart were normal. The deep incisional skin biopsy taken from the subcutaneous nodule revealed leukocytoclastic vasculitis of the dermal vessels [Figures 2a and b]. The patient was treated with methyl prednisolone (three pulses doses of 750 mg/day) followed by oral prednisolone of 1 mg/kg/day. She also received a course of oral penicillin for antecedent streptococcal throat infection. The skin lesions completely healed over a period of six months with scarring [Figures 3a and b], and patient was on regular follow up for one and half year after which she lost to follow up and treatment.
She presented to us again in July 2010 (three years after the initial episode in December 2007) with similar complaints of bluish black discoloration of left middle finger and subcutaneous nodules. The skin biopsy was repeated which showed leukocytoclastic vasculitis of the dermal vessels suggestive of CPAN. There was no systemic involvement by clinical examination and investigations. The ASLO titer was normal. The patient was treated with injection cyclophosphamide 750 mg/meter square (6 pulse doses every month) and advised to continue steroids (prednisolone 30 mg/day) and methotrexate 7.5 mg/week. Her symptoms completely resolved in two weeks time. The patient is on regular follow up in our immunology clinic and there is no further episode of relapse till date.