Clinical Images: Co‐occurrence of Bywaters lesions and Jaccoud arthropathy in a patient

The patient, a 60-year-old Han Chinese woman, has a long-standing diagnosis of systemic lupus erythematosus (SLE) treated with prednisone, hydroxychloroquine, and mycophenolate. She has had arthritis, pleurisy, pleural effusions, fevers, rash, and sudden-onset sensorineural hearing loss, as well as anemia, neutropenia, and lymphopenia. She has high-titer antinuclear antibodies, positive anti-Sm and anti-RNP, elevated anti–double-stranded DNA (>500 IU/mL), and low complement levels. There were reddish purple infarctions around the nail folds of multiple fingers (A). The lesions were asymptomatic, persisted for several weeks, and then resolved. These were suggestive of Bywaters lesions, which are more frequently described in rheumatoid arthritis (RA). She has chronic reducible deformities of the bilateral first carpometacarpal, multiple metacarpophalangeal, proximal interphalangeal, and particularly the distal interphalangeal joints. Radiography of the hands showed an absence of erosions or cartilage loss, confirming a diagnosis of Jaccoud arthropathy as first described by Bywaters in patients with SLE (B). Bywaters lesions are an uncommon cutaneous vasculitis usually seen in patients with RA. They are caused by small vessel vasculitis and thrombosis of small nail fold or digital pulp vessels.1 Bywaters lesions in SLE are rarely described even in cohorts of patients with SLE studied because of cutaneous lesions on their digits.2 Both Jaccoud arthropathy associated with SLE and Bywaters lesions were first described by British physician Eric Bywaters in the 1950s and 1970s, respectively.3 We report this patient because of the interesting co-occurrence of unusual disease manifestations described by a single physician. Informed consent has been obtained from the patient. Open access publishing facilitated by University of New South Wales, as part of the Wiley - University of New South Wales agreement via the Council of Australian University Librarians. Disclosure form. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.