SHM Converge Scientific Abstract ePoster Gallery-Going but Not Gone: A Case of Rheumatoid Vasculitis

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This case describes a 79-year-old woman with longstanding seropositive, erosive, nodular rheumatoid arthritis who presented with a rapidly enlarging, non-healing lower leg ulcer initially concerning for cellulitis. Her history was complicated by large granular lymphocytic leukemia and Felty syndrome, with splenomegaly, severe neutropenia, and prior filgrastim use for low white blood cell counts. On exam, she had advanced chronic rheumatoid deformities but no active synovitis or signs of cellulitis. Laboratory testing showed marked leukopenia and neutropenia.<br /><br />A skin biopsy of the ulcer revealed leukocytoclastic vasculitis, leading to a diagnosis of rheumatoid vasculitis. Filgrastim was stopped because of concern it could worsen vasculitis. Treatment decisions were complicated by her high infection risk due to leukemia, Felty syndrome, and neutropenia, making standard immunosuppressive therapy potentially dangerous. After multidisciplinary discussion with infectious disease and hematology, and shared decision-making with the patient, rituximab was started before discharge because the team felt the risk of progressive ulceration and possible amputation outweighed the infection risk.<br /><br />The poster highlights that rheumatoid vasculitis is a rare but serious extra-articular manifestation of rheumatoid arthritis, most often cutaneous but potentially affecting any organ. It carries significant mortality, with reported five-year mortality of 30–50%. Its incidence has declined in recent years, likely because of improved rheumatoid arthritis treatment. Biologic therapy, especially rituximab, can induce remission in many patients, but adverse events, particularly infections, remain a major concern. The case emphasizes the need for careful risk-benefit assessment and patient counseling when treating rheumatoid vasculitis.

Asset Subtitle

Patricia Carey

Meta Tag

Author List Jeffrey Yang, Kenneth J. Warrington, Patricia Carey

Category Clinical Vignettes

Concept Rheumatoid Vasculitis

Concept Leukocytoclastic Vasculitis

Concept Rheumatoid Arthritis

Concept Cutaneous Small-Vessel Vasculitis

Concept Lower-extremity Ulcer

Distinguished Non-Finalist

Presenter Organization Mayo Clinic

Presenting Author Patricia Carey

Track Adult

Keywords

rheumatoid vasculitis

rheumatoid arthritis

leukocytoclastic vasculitis

non-healing ulcer

filgrastim

Felty syndrome

large granular lymphocytic leukemia

neutropenia

rituximab

cutaneous vasculitis

Rheumatoid Vasculitis

Leukocytoclastic Vasculitis

Rheumatoid Arthritis

Cutaneous Small-Vessel Vasculitis

Lower-extremity Ulcer