An 8-Year-Old Boy With Prolonged Fever and Subcutaneous Nodules

An 8-year-old boy with asthma presented with prolonged fever, malaise, extremity weakness, polyarthralgias, malar rash, and subcutaneous nodules. Physical examination was remarkable for a faint malar rash, flesh-colored papules on the dorsal aspect of the fingers, arthritis of multiple joints in the hands, and subcutaneous nodules. The nodules were firm, nontender, and distributed over multiple extremities and the trunk. The patient was admitted to expedite workup. Initial laboratory test results revealed leukopenia, mild elevation of the aminotransferases, an elevated erythrocyte sedimentation rate, and normal level of creatine kinase. His echocardiogram was normal. Infectious disease studies were negative. Additional examination revealed dilated capillaries in his nail beds and bilateral hip weakness. MRI of his extremities was negative for myositis or calcification of the nodules. We obtained a biopsy of the subcutaneous nodules, and because the patient remained afebrile during the hospitalization, we discharged him from the hospital with outpatient follow-up. Our expert panel reviews the course of the patient's evaluation and investigation, as well as the implications of his diagnosis based on the tissue pathology from the nodule biopsy.