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JAMA Ophthalmology Clinical Challenge |

Conjunctivitis, Fever, and Tender Skin Nodules—Quiz Case

Sotiria Palioura, MD, PhD; Adriano Piris, MD; James Chodosh, MD, MPH
JAMA Ophthalmol. 2013;131(6):791. doi:10.1001/jamaophthalmol.2013.4495a .
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A 68-year-old man came to the emergency department with a 4-day history of abrupt-onset fever, maculopapular skin rash, bilateral eyelid pain, redness, and discharge. His medical history was significant for ulcerative colitis, which was treated with mesalamine and azathioprine. He experienced an ulcerative colitis flare 2 months prior to presentation that required a high dose of prednisone. His visual acuity was 20/30 OU. Ocular examination revealed tender, erythematous, and edematous eyelids bilaterally with eyelid margin ulcerations, subconjunctival hemorrhages, and mucoid discharge (Figure 1). His corneas were clear and no intraocular inflammation was noted. The remainder of findings from the ocular examination, including funduscopic examination, were unremarkable. Tender skin nodules were noted on his forearms, neck, and abdomen (Figure 2A). Over the next 2 days, the patient remained febrile and the skin nodules became pustules (Figure 2B). His eyes remained inflamed despite use of topical steroid and antibiotic ointment.

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Figure 1. Patient's eyes at presentation. His eyelids are edematous and erythematous with eyelid margin ulcerations. Subconjunctival hemorrhages and mucoid discharge are also present.

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Figure 2. Patient's forearm. A, Tender skin nodule at presentation. B, Two days later, the same nodule had evolved into a pustule.




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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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