Resumen
Introducción: el 20-40% de los pacientes con artritis reumatoide (AR) presentan una manifestación extraarticular (MEA) y del 1 al 20% una MEA grave, con un riesgo incrementado de muerte (> 2 veces). Las lesiones asociadas son: 27.5% nódulos reumatoides y en 0.5% dermatitis neutrofílica, dermatitis granulomatosa en empalizada o vasculitis cutánea.
Caso clínico: mujer de 52 años que presentó súbitamente una úlcera cutánea dolorosa en dorso de pie izquierdo con bordes violáceos, bien definidos, sobreelevados y tejido de granulación con natillas fibrinopurulentas, con halo edematoso y posterior formación de costra e hiperpigmentación perilesional. La lesión no mostró mejoría a pesar de aseos y antibiótico. Se reportó biopsia con abundantes neutrófilos en dermis y vasculitis. Los estudios paraclínicos presentaron: proteína C reactiva: 32.5 mg/dL, velocidad de sedimentación globular: 59 mm/h y factor reumatoide (FR): 2460 U/mL, además de anticuerpos antinucleares (1:640), anti-DNA negativo y anticuerpos antipéptido citrulinado (anti-CCP) positivos (221.70 U/mL), lo cual confirmó diagnóstico de AR.
Conclusiones: la vasculitis reumatoidea es la MEA más grave de la AR, con más de 40% de pacientes fallecidos a 5 años del inicio. Es una complicación poco común y más frecuente en hombres con AR de larga evolución. Destacamos la importancia de sospechar de patología autoinmune, especialmente AR, ante úlceras cutáneas espontáneas, sin componente infeccioso y con alteraciones en la analítica básica.
Abstract
Background: 20-40% of patients with rheumatoid arthritis (RA) present an extra-articular manifestation (EAM) and 1-20% a severe EAM, with an increased risk of death (> 2 times). The associated lesions are: 27.5% rheumatoid nodules, and 0.5% neutrophilic dermatitis, palisaded neutrophilic granulomatous dermatitis, and/or cutaneous vasculitis.
Clinical case: 52-year-old woman who suddenly presented with a painful skin ulcer on the dorsum of the left foot with violaceous, well-defined, raised edges and granulation tissue with fibrinopurulent membranes, with an edematous halo, and subsequent crusting and perilesional hyperpigmentation. The lesion did not show improvement despite debridement and antibiotics. Biopsy with abundant neutrophils in the dermis and vasculitis was reported. Paraclinical testing showed: C-reactive protein: 32.5 mg/dL, erythrocyte sedimentation rate: 59 mm/h, and rheumatoid factor (RF): 2460 U/mL, in addition to antinuclear antibodies (1:640), negative anti-DNA, and anti-citrullinated protein/peptide antibodies (ACPA/anti-CCP) positive (221.70 U/mL), confirming the diagnosis of RA.
Conclusions: Rheumatoid vasculitis is the most serious EAM of RA, with more than 40% of patients dying 5 years after clinical onset. It is a rare complication and more common in men with longstanding RA. We highlight the importance of suspecting autoimmune pathology, especially RA, in the presence of spontaneous skin ulcers, without an infectious component and with alterations in the basic laboratory tests.
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