Cedilla

You are doing telemedicine and get these pictures from patients in Turkey. Patients are 20-40 years old and have recurrent painful lesions shown above. HSV is negative. They tend to be extensive and patients can have multiple lesions. For some patients, the pain is so bad they can barely eat anything. Yet the ulcers heal by themselves within 1-3 weeks.

Some patients get genital HSV screening too because they complain about the same lesions on the scrotum and vulva; often, these even lead to scarring. When doing a thorough skin exam, there are many varied lesions which can be acneiform, papulo-vesiculo-pustular, pseudofolliculitis, nodules, erythema nodosum, superficial thrombophlebitis, pyoderma gangrenosum, erythema multiforme, and palpable purpura. If you prick the skin with a needle, a pustule-like lesion or papule may form.

Eye abnormalities are also common, involving bilateral episodic uveitis, occasionally with purulence in the anterior chamber. Rarely, neurologic involvement may cause focal deficits. Some people present with hemoptysis. Others have recurrent DVTs. Most patients have a nonerosive asymmetric nondeforming arthritis of the knees, ankles, and wrists.

Challenge: What's your diagnosis?

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