A patient with skin and bone lesions.

362 A 39-year-old nurse was referred for evaluation of bone lesions. Seven months earlier she had undergone a hysterectomy because of severe vaginal discharge and urge incontinence. Two months after the operation, she noticed pain in the mid left clavicula. There was no trauma, fever, redness or swelling. In the same period she developed red, itchy and scaling skin lesions of both hands, left foot, right ear and forehead, as well as recurrent oral aphthae. Two months later she noticed a painful swelling at the left clavicula. An X-ray of the clavicula showed an old fracture with callus formation. X-rays of the skull, the chest and mammography were normal. Laboratory tests showed an ESR of 16 mm, aspartate aminotransferase 66 U/l, alanine aminotransferase 141 U/l, GT 23 U/l and lactate dehydrogenase 299 U/l. Histology of fine needle biopsy of the clavicula showed chronic osteomyelitis with extensive fibrosis and perostitis (figure 1). Cultures were negative. Bone scintigraphy showed increased uptake in the left clavicula, right clavicula and parasternal region five minutes after injection; three hours after injection increased uptake was seen at the right skull (figure 2). On physical examination there was a slight tenderness over the left clavicula. The skin showed red, non-vesicular, eczematous scaling lesions on hand palms, ears and forehead; there were aphthous ulcers in the mouth and the perianal region.