Coincidence of Tender Facial Swelling and Painful Calf Lesions in a 23 Year Old Woman

A 23 year old female was admitted to Internal Medicine department due to bilateral face swelling of both preauricular area and multiple tender small lesions in the anterior aspect of both calves. A few similar lesions were found on the posterior aspect of her arms. She had a prodrome of two days fever before and upper dysphagia and odynophagia a day before her admission. She reported of mild alcohol consumption and childhood asthma. She did not take any medication prior to her admission except oral contraceptives, which were prescribed for a few weeks, until 4 months ago. On physical examination, the patient seemed to have bilateral tender swellings of both preauricularareas ,that were painful while opening her mouth (Figure 1). She also had bilateral tender erythematous lesions on both calves and a few similar lesions involving the extensor portion of her arms (Figure 2). The lesion borders were poorly defined, and lesions vary from 2-5 cm. The rest of physical examination was within the normal range. Laboratory examination included elevated CRP (133 mg/dL, norm<0.5 mg/dL). CBC, liver functions and renal functions were all within the normal range. Blood cultures, serology for HAV, HBV, HCV, EBV, CMV and HIV and Mantoux test were negative. Antinuclear antibody was weak positive (+1), complement levels (c3 & c4) were in normal range and Rheumatoid Factor was negative. Beta HCG was negative (<0.6). Chest X-ray was without pathologic findings.