26441 Palisaded and neutrophilic granulomatous dermatitis in a child

Palisaded and neutrophilic granulomatous dermatitis (PNGD) is a rare entity that occurs in conjunction with autoimmune diseases as systemic lupus erythematosus (SLE), rheumatoid arthritis (RA), juvenile idiopathic arthritis, sarcoidosis, and mixed connective tissue disease. Autoimmune diseases in pediatric patients can be challenging to diagnose. We present the first pediatric case of PNGD associated with SLE. A 10-year-old girl with a history of atopic dermatitis, asthma, and a family history of SLE and RA presented to the ED with palpable purpura of the lower extremities and arthralgias and was diagnosed clinically with Henoch- Schoenlein purpura. She was treated conservatively, and her rash resolved, but she continued to have arthralgias which were attributed to “growing pains.” Six months later she presented to the dermatology clinic with a new papular rash on the elbows and knees as well as photosensitivity. She was found to have an ANA of 1:2560 and dsDNA antibodies of 109, anti-SSA/anti-SSB were negative. Biopsy of a papule on the elbow revealed PNGD. While the patient’s biopsy was being processed, she acutely developed worsening arthralgias, muscle weakness, and fatigue and was admitted to the hospital where she was found to be hypertensive. During this admission, patient met criteria for diagnosis of systemic lupus erythematosus and renal biopsy revealed class IV lupus nephritis. Patient was started on IV solumedrol, amlodipine, and rituxumab infusion, and improvement was seen in her systemic and cutaneous symptoms.