LAUSR

cases histiocytes, 33.3% eosinophils, and 22.2% lymphocytes. In 66.6% of the cases, fat necrosis was found. Vascular damage was observed in 87.5% of the cases with vasculitis, vascular disruption, or perivascular karyorrhexis, but only three cases (33.3%) showed overt vasculitis as in our case. It is problematic to evaluate the response to different treatments. At least two cases, including ours, resolved without treatment, but some of the cases required extensive immunosuppressive therapy and even one of the cases died of sepsis because of treatment complications. Regarding the pathogenesis of this panniculitis, similar to other small vessel vasculitic processes, including rheumatoid vasculitis, increased levels of immune complexes have been postulated, and this is consistent with the fact that more than half the patients present with polyclonal hypergammaglobulinemia and an increased RF titer. In our patient, the vascular damage was sequential and is the only case reported with such findings. In most of the other cases, the vascular damage observed seemed to translate in ischemic changes leading to fat necrosis. After our literature review, we think that females with longstanding RA and increased RF titers with a nodular syndrome should be biopsied to avoid a misdiagnosis of EN, a more common panniculitis.