8221281 tn?1397570972

42 days Skin rash

I am a 24 year old female
ANA positive 320 with two patterns Homogenous and Speckled.
High CRP
HZ igg was recently positive at 1,165 (cutoff is >200)
Symptoms began on March 15th I had fever and swollen joints and lymph nodes for one day. Followed by blistering rash which spread over the next ten days primarily on the left side from the top of my left breast up to the left side of my face. It burned, and was very painful. A doc in the Box diagnosed me as having a staff infection and treated with Doxycycline. This did not help. 2 weeks later he cultured the original lesion and put me on doxycycline. The culture came back negative. I noticed milk leakage and saw OB who suspected Shingles with a secondary complication as evidenced by the diffuse pattern of rash which was different from the healing primary rash. She tested Prolactin, CBCw/Diff and CMP, ANA +Titer, CRP (We already know I have Lupus and am suspect for some kind of secondary connective tissue disorder but are unable to determine which one right now) My Lupus had complications in 2009 as my primary serious organ involvement is my vascular system. Before getting treatment I had a thrombocytic event which required subclavian bypass. Afterwords I began treatment for Systemic Lupus with Methotrexate,  Plaquenil, and Prednisone and Lovenox.  Eventually I was able to get off of prednisone and it has only been used when lupus becomes active or signs of vasculitis return. I was taken off of Methotrexate in November 2013 as I had a minor surgical procedure. Rheumatology wanted me to try to stay just on Plaquenil as my Lupus had been quiet for some time at that point. I was officially listed as in remission by January 2014.  My Lupus tends to stay dormant unless there are changes in Hormones, or I get a Virus or Bacterial infection that is significant. Most minor viral infections don't trigger it but Strep and Kidney infections after resolution I can usually count on a Lupus flare about 2-3 weeks after the infection is resolved.    I have an appointment with Dermatologist at a University Hospital who specializes in autoimmune patients.  My rash has been lingering for about 43 days now.  The University Hospital had me migrate my symptom treatment back to my primary Care provider as the Doc in the Box seemed incompetent.  My PCP carefully looked over my body and in addition to the rash shown in the image, Levido Reticularis was noted in my arms, hands, legs and feet in the absence of a cold environment. Low grade fever noted in addition to malaise. Unable to wear bra due to intense burning and irritation. Additionally physician noted, what appeared to be petichae in my upper arms and back of the bottoms of my legs.  More lesions similar to the ones on my chest were found on my back diffusely and sporadically on my legs. The lesions on my legs were palpable, one color and not raised or indented. They differed in that they did not itch. I was not aware of them until physician pointed them out. They appeared to be more consistent with petichiae or purpura.  A few on my arms and face. Mostly, the serious outbreak has primarily clustered on my chest and face.  With the combination of my history, the clinical signs of vasculitis in addition to what appears to him to now be cutaneous expression of lupus he put me on oral Prednisone. I had asked the Doc in the Box for steroids to try since once we ruled out bacterial infection but he refused. (which is why University had me transfer care back to my PCP)  My PCP did not say that he knew for sure what was causing the problem but he guestimated it was autoimmune in nature and my clinical presentation was similiar to other Lupus patients he had seen in the past. He wanted me to take Oral steroids for at least three days to see if there was an improvement. He wants me to stop the oral steroids on Monday so that the oral steroids have less chance of interfering with the testing Dermatology may want to do. Dermatology was fine with 3 day oral steroid treatment.  In less than two days I had the first significant improvement in the entire course of this break out and treatment.   Does this mean that this is lupus related? Or does this just mean that prednisone relieved the inflammation? The livedo reticularis is significantly lighter and the petichiae appear to be lightening up. My joints are still arthralgic and swollen in the morning but oral steroids don't usually result in significant improvement in joint involvement until about 4-5 days into treatment based on trend of past treatment and its response to joint involvement.
Note that despite being tested positive for Vasculitis via biopsy in the past, The last time my Rheumatologist did bloodwork for antibodies most commonly associated with vasculitis was in 2010 I was not positive for Anti-RO or ANCA at the time my hsCRP and CRP were high but my ESR was only mildly elevated during that 2010 lab draw.

Is there a specific type of biopsy that the Dermatologist should do to rule out or in autoimmune rash, that would also loo for other types of cells like allergic reactions, leukocytosis, vasculitis etc. The original dermatologist did a Scrape biopsy to rule out cancer and fungal/bacterial organisms. I've been told that Punch biopsies are more efficient for checking for multiple causes. Should I request the Dermatologist to repeat the CBC w Diff, CRP and ESR (three weeks since last blood work) My ESR was good but my CRP was high then. Are there other blood labs recommended to add for this? My thyroid is fine and this is not thyroid related anyway. I am tagging this as subacute since the condition has lasted more than 40 days.  Any responses appreciated. I realize that this forum is not a substitute for professional medical advice. Your response will not be taken as such but merely as opinion.  I appreciate your help. The image attached is not copyrighted and you are free to use it for whatever purposes.  I note that as several users in the Dermatology forum appear to collected images for research and clinical purposes. If higher quality images are needed or wanted let me know.
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