A 55-year-old man with a 5-year history of multiple sclerosis had been treated subcutaneously for 4 years with GA 40 mg 3 times weekly. He changed injection sites every time (abdomen, ventral thighs, buttocks) and experienced occasional mild injection site reactions with coin-sized skin swelling and induration, which resolved within weeks. Approximately 30 s after the last injection in the lower left abdomen, the patient experienced a sudden-onset intense, radiating pain. Two minutes later, he developed an extended urticarial swelling with erythematous borders mainly on the left side of his abdomen. The irregular reticular and serrated lesions also extended to the right side (Figure 1a). There were no systemic symptoms. He was treated with intravenous glucocorticoids, and the swelling resolved within hours.
Two days later, a livid erythematous macula with irregularly serrated margins developed. The patient suffered from severe abdominal pain and was admitted to the hospital. He received intravenous meropenem and linezolid for 2 days.
A week later, he presented at our department with well-demarcated reticular erythema of 10 × 15 cm with central blisters and peripheral induration (Figure 1b). A routine blood test revealed mildly increased C-reactive protein and creatine kinase, serological autoimmune parameters including autoantibodies to extractable nuclear antigens and double-stranded DNA, lupus anticoagulant, and cryoglobulins were negative. Skin swabs showed resident flora. Ultrasound showed a diffuse increase in echogenicity of subcutaneous tissue (Figure 2), as a nonspecific demonstration of inflammation observed, for example, in lymphedema and cellulitis. Histopathologically, there was necrosis of the epithelium and sweat glands, thrombosed small vessels, neutrophil infiltration and hematoma in the dermis, but no evidence of primary vasculitis (Figure 3). Direct immunofluorescence was without pathological findings.
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