What is your diagnosis? Leg ulcers in SLE

Abstract

A 25-year-old female, known case of systemic lupus erythematosus (SLE) for 1 year presented with a 3 months history of painful ulcers over right leg and foot. The lesions were preceded by an injury and started as bullae which got ulcerated. There was no history of pain abdomen, bloody diarrhoea, jaundice, pain or swelling in joints, any bleeding tendency, cough, chest pain, polyuria, polydypsia or polyphagia. Also there was no history of any drug intake known to cause leg ulceration. General physical examination revealed pallor and oedema of right leg and foot. Cutaneous examination revealed malar rash, lupus hair, livido reticularis of trunk and limbs and multiple well-defined ulcers distributed on right leg and foot (Fig. 1) ranging in size from 2 × 2c m to 8 × 5 cm with purplish punched out borders and a necrotic base studded with small abscesses extending down to the deep fascia. Cutaneous tenderness was present. All peripheral pulses were normally palpable and sensations over both feet and legs were normal. Mucosae, palms and soles were free from any lesions. Investigations revealed a haemoglobin of 8 gm/dL, a positive direct coomb’s test, antinuclear antibody (ANA) and anti double stranded DNA (anti ds-DNA) was positive, anti-cardiolipin antibody and lupus anticoagulant and antineutrophilic cytoplasmic antibody (c ANCA) were negative, a blood urea of 77 mg/dL and serum creatinine of 3.5 mg/dL with a normal radiograph of right leg and foot. Venous and arterial duplex sonography of the right leg showed no evidence of reduced perfusion or arteriosclerosis. Edge biopsy of the lesion revealed epidermal and dermal necrosis with central intense neutrophilic infiltrate and a peripheral mixed inflammatory infiltrate. What is your diagnosis?