Leflunomide, a disease-modifying anti-rheumatic drug, decreases pyrimidine synthesis through dihydroorotate dehydrogenase inhibition and down-regulates tumor necrosis factor-alpha. 1 Nail disorders due to leflunomide have an incidence of 1 to <3% in rheumatoid arthritis (RA) patients. 2 We report a case of 67-year-old male with nail changes after leflunomide initiation. He had a history of seronegative RA with bilateral 2nd/3rd metacarpophalangeal (MCP) joint involvement; all other joints remained spared. Due to patient preference and previous tolerance, leflunomide therapy was started. Methotrexate was forgone due to chronic alcohol consumption. Three months after initiation he noticed gradual 20-nail change and destruction (Figure 1). Nail avulsion showed no evidence of fungal elements. On physical examination, all 20 nails were yellow, thickened, and dystrophic (Figure 2). While psoriatic arthritis (PsA) was considered, he did not report
We present the case of a 44-year-old man with a complicated past medical history who presented with presumed sepsis secondary to pneumonia and severe joint pain secondary to gout. Despite an entirely negative infectious workup during his lengthy hospitalization, he developed ulcerated, draining wounds on his hands and feet that were also initially presumed to be infectious. The chalky substance draining from the wounds was eventually evaluated with potassium hydroxide under polarized microscopy and found to have the characteristic negative birefringence of sodium urate crystals. He was treated with steroids after an infectious etiology had been ruled out, and he improved clinically once his uric acid levels began to fall.
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