Cutaneous Ulceration and a New Cardiac Murmur in a Young Woman

Abstract

REPORT OF A CASE A 25-year-old woman presented with a 6-week history of an ulcer on her left middle toe, which persisted despite a 4-week course of cephradrine. She complained of mild fatigue but denied fever, chills, or night sweats. Her medical history was significant for Graves' disease and, at age 16 years, an episode of streptococcal pharyngitis complicated by chorea. She had no history of a heart murmur and had never been pregnant. Physical examination revealed an afebrile, obese white woman whose vital signs were stable. Prominent livedo reticularis on the hands, ankles, and feet; periungual erythema; and splinter hemorrhages on the left thumb and right index finger were observed. A 2-cm punchedout ulceration with violaceous borders was present on the medial aspect of her left middle toe ( Figure 1 ). Cardiac examination disclosed a new grade II/VI holosystolic murmur localized to the apex and accentuated in the left lateral