To the editor: A 30-year-old rheumatology fellow developed severe joint tenderness and ecchymotic lesion over the flexor surface of the right second distal interphalangeal joint. The lesion appeared abruptly, about 20 minutes before evaluation. He denied constitutional symptoms except fatigue; findings in a limited physical examination were normal except for facial hirsutism and (male pattern) alopecia.
The patient adamantly refused biopsy but consented to be photographed (see Figure 1). After extensive evaluation over the next 30 minutes, a specific cause could not be found. Immune complexes, however, were not sought.
A short time later, over a can of beer, the