Facing uncertainty

A 57-year-old woman presented to a dermatology clinic with a 1-year history of an itchy facial rash. An outside provider had diagnosed her condition initially as allergic contact dermatitis to poison ivy and, when the rash persisted, as systemic lupus erythematosus (SLE) on the basis of the facial distribution and a skin biopsy showing an interface dermatitis. Before presentation at the dermatology clinic, she had been treated with prednisone (40 to 60 mg daily) and hydroxychloroquine for 3 months but had no clinical improvement. Redness had spread from her face to her scalp and neck. She reported a productive cough and progressive dyspnea for the preceding 2 weeks. She reported no chest pain, joint pain, muscle weakness, or leg swelling.