Multiple cutaneous abscesses in a patient with Sjögren's syndrome

A 63-year-old woman presented with multiple tender, nonulcerating, erythematous nodules on her right hand and forearm for 10 days (Figure 1A). She was suffering from Sjogren’s syndrome for more than 1 year and had been treated continually with azathioprine and prednisolone. Under the tentative diagnosis of erythema nodosum, an incisional biopsy was performed on her right forearm. Histopathology showed septolobular panniculitis, heavy infiltrates of neutrophils and granulomatous inflammation (Figures 1B and 1C). Periodic acid-Schiff (PAS) and acid-fast stains were negative. She was then treated with prednisolone 20 mg per day for suspected autoimmune panniculitis. The patient returned to our clinic 2 months after initial presentation. Multiple erythematous to purpuric macules, papules, and punched out ulcers spread centripetally over the patient’s four extremities in a symmetrical distribution (Figure 2A). Tender erythematous nodular eruptions without ulcerations similar to her previous skin lesions at initial presentation were found over both hands and forearms (Figure 2B). There were no associated systemic symptoms, such as fever, chilling and myalgia. She was treated with higher dose of prednisolone of up to 60 mg per day for suspected autoimmune vasculitis by the rheumatologist. However, more papulonodules, ulcers and pustules developed over her extremities as we tapered the dose of systemic steroid. Another skin biopsy of a fresh pustule from her right hand was taken and submitted for both histopathology and culture. Acid-fast positive bacilli were found (Figure 3).