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250 QUIZ SECTION Fast-growing Painful Leg Ulcers in a 26-year-old Woman with Systemic Lupus Erythematosus: A Quiz Julia HARTMANN, Holger A. HAENSSLE, Alexander H. ENK and Ferdinand TOBERER Department of Dermatology, Venereology and Allergology, University Medical Center, Ruprecht-Karls-University, Im Neuenheimer Feld 440, DE-69120 Heidelberg, Germany. E-mail: [email protected] A 26-year-old woman presented with an 8-month history of a fast-growing, painful ulceration on her right lower leg (Fig. 1). The patient’s medical history included systemic lupus erythematosus (SLE), antiphospholipid syndrome, arterial hypertension, hypothyreosis and ovarian cysts. One year previously the patient had had a stroke and Libman- Sacks endocarditis. Her current medication included 100 mg azathioprine, 5 mg prednisone and 150 mg hydroxy- chloroquine per day, in addition to rivaroxaban. Initially, the lesion had presented as a painful bluish discoloration with no epidermal involvement and had first been recognized by the patient as a bruise. The patient was referred to the department of surgery. Sonography and a magnetic resonance imaging (MRI) of her right lower leg were performed and the findings were compatible with an organized haematoma. Therefore the lesion was incised and drainage was inserted. Following this procedure a second smaller lesion developed where the drainage had been lo- cated. As neither lesion healed the patient was referred to our dermatology outpatient department. Fig. 1. (a) Lower right leg with 2 partially ulcerated lesions measuring approximately 3 cm and 6 cm in diameter. (b) Six weeks later the lesions measured approximately 4 cm and 10 cm in diameter, with a purulent exudate, slightly undermined borders and livid discoloration of the perilesional skin. What is your diagnosis? See next page for answer. doi: 10.2340/00015555-3044 Acta Derm Venereol 2019; 99: 250–252 This is an open access article under the CC BY-NC license. www.medicaljournals.se/acta Journal Compilation © 2019 Acta Dermato-Venereologica.