General dermatology & dermatology in primary health care.

A woman in her late 50s presented with rapidly progressing, painful nodulo-ulcerative lesions on bilateral forearms that ulcerated and bled within two weeks of onset. She reported low-grade fever, productive cough, epistaxis, myalgias, and bilateral mixed hearing loss. Investigations revealed microcytic hypochromic anemia, elevated erythrocyte sedimentation rate, hematuria, and lobulated opacities in the chest. A skin biopsy showed dermal neutrophilic infiltration, vessel destruction, and granulomas, with negative stains for tuberculosis and absence of fungal elements.