Annual Meeting Image Competition

Sabrina Machado, MD
São Paulo, Brazil

A 13-year-old boy presented a 7-year history of erythematous and highly hyperkeratotic plaques affecting his palms (A) and soles (D), refractory to topical treatments, methotrexate and acitretin previously prescribed by his dermatologist. He denied any musculoskeletal complaints or systemic symptoms. Physical examination revealed painless significant wrist enlargements and claw-like flexed fingers sparing distal interphalangeal joints (C). His hand X-rays showed acro-osteolysis (B) and power doppler ultrasound revealed nail thickening. A diagnosis of palmoplantar psoriasis with subclinical psoriatic arthritis was considered.

Noor Alanni, BAO, MB, MBChB
Doha, Qatar

A 10-year-old boy, presented with a 5-year history of recurrent right knee pain and swelling, associated with mildly elevated inflammatory markers. Ultrasound of the right knee demonstrated a lobulated echogenic mass with frond-like projections in the suprapatellar region with joint effusion (A). The sagittal view MRI showed a suprapatellar heterogenous high signal mass at the suprapatellar pouch with frond-like projections (B). This mass was suppressed in the fat saturated MRI reflecting the fat component of the lesion surrounded by a hyperintense effusion (C) characteristic of lipoma arborescens.

Eaman Alhassan, MD
Pittsburgh, Pennsylvania

A 3-year-old boy presented with a 4-month history of rash and “hand blisters”. Physical examination showed heliotrope rash, Gottron papules (A), papules on the palmar creases of the fingers consistent with kissing papules (B), and erythematous desquamative plaques on the back of the toes (C). Laboratory tests revealed a positive MDA-5 autoantibody and normal muscle enzymes. Subtle myositis was evident on the MRI scan. HRCT of the chest was normal. “Kissing papules” refers to papules occurring on the palmar creases of the fingers, forming symmetrical lesions on each side. It is one of the unique cutaneous characteristics of anti-MDA-5 dermatomyositis.

Sarath Chandra Mouli Veeravalli, MD, MRCP
Hyberabad, Telangana, India

A 9-year-old boy presented with migratory joint pains, swelling, low-grade fever, sore throat, and skin rashes. Examination revealed joint tenderness (Fig A) and erythema marginatum (Fig B). Investigations showed elevated ESR, high ASO titer, diffuse T wave inversion in ECG (Fig C) and mild to moderate mitral regurgitation on echocardiogram. Diagnosis was confirmed as acute rheumatic fever (ARF) using revised Jones criteria, highlighting carditis and polyarthritis. The case underscores the importance of early recognition and management of ARF to prevent severe cardiac sequelae and the necessity of secondary prophylaxis to mitigate chronic valvular heart disease risks.