Erythema of unclear etiology

A young woman, born 1989, came for a routine control visit. Her disease had been classified as an undifferentiatiated autoimmune connective tissue disorder. She had been treated with azathioprin and mycophenolate mofetil. She developed a primarily toxic liver cell damage and had to be taken off medication.


Lab findings:
25-OH D3 6 ng/ml, CRP 14 (9.8) mg/l, Gamma-GT 61 (21), GOT 487, GPT 600 (100)U/l, IgG 4.114 mg/dl, C4-Komplement 8, Rheumafaktor 65 IU/ml, ANA >1:1.280, granular, nucleolar, ds-DNA-Ab 17 IU/ml, ENA-Blot: Ro(SSA), Ro52(SSA), CENP B positiv; p-/c-ANCA, SMA, LKM-AK und AMA negative . negativ bestimmten Werte für)


Liver histology:
Portal and intralobular lymphocytic and granulocytic hepatitis with single cell necrosis and gruoped cell necrosis, focal granulomatous hepatitis and focal proliferation of biliary as well as portal, incomplete sept creating fibrosis and pericellularr fibrosis (activity level II-III, Fibrosisstadium II according to DeSmet). No fat accumulation in liver cells, no cholestasis or siderosis.
Assessment: primarily toxic liver cell damage. In view of the increased values for antinuclear antibodies one should laso consider a combination of toxic liver cell damage with an autoimmune hepatitis. The histologic image is not typical for primary sclerosing cholangitis or a primary biliary cirrhosis.


She has been put on low dose morphine by a pain specialist and is doing fine in all aspects. All but one: she has developed a new erythema that doesn’t itch, which surrounds hypo pigmented, confluent circle lesions. Here’s a picture:

Any ideas, what it is? No, it isn’t pityriasis versicolor, not lichen sclerosus et atriphicus (Csillag’s disease), nor morphea. The dermatologist, which our patient had consulted already, didn’t have any idea of what this erythema could be.

Someone just told me the solution to this puzzle. I will put the solution on the blog in about 24 hours, just in case s.o. wants to research further. 24.05.2012/15:50 MEZ

And here is the solution; Beez has sent the following two tweets concerning the problem:
@beezknez hi was looking at the pic on blog re unclear etiology she isn't perhaps having an opioid reaction to the morphine ..?

@beezknez just her skin looks similar to what i have seen with ppl who have used oxy co & long use of opioid drugs esp morphine ..
And this is what had happened: She has been put on low dose morphine by a pain specialist