What would you order next?
Hemorrhagic Vesicles in a Woman with Arthralgias and Eye Pain A 48 yo had 6 months of arthralgias in her extremity joints, 3 weeks of a purpuric rash and foot paresthesias, and 2 weeks of bilateral eye pain and redness, all unresponsive to 4 days of prednisone treatment (10 mg/d). She had no fevers, epistaxis, rhinorrhea, cough, shortness of breath, hematuria, history of travel, or illicit drug use. On examination she had bilateral scleral injection and swelling and tenderness over her PIP joints bilaterally with hemorrhagic vesicles and violaceous papules on her ears, nose, arms, and legs. She had normal U/A, CBC, electrolytes, and LFTs. Punch biopsy of a papule on the right arm demonstrated a superficial perivascular infiltrate of neutrophils with leukocytoclasia, extravasation of erythrocytes, and fibrin in small blood vessel walls, negative on DIF for in situ deposits of IgG, IgA, IgM, and C3. What would you order next? A. ANCA titers B. Chikungunya serology C. Echocardiogram D. Urine nucleic acid amplification test for Chlamydia infection
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