Urticarial vasculitis: An unusual manifestation of ‘rhupus’

A 43-year-old kind lady presented to the clinic for rheumatological evaluation for chronic worsening joint pain and associated morning stiffness with family history of rheumatoid arthritis (RA) in her father and a daughter who is HLA-B27 positive. After initial clinic presentation, the patient was hospitalized for acute onset of a truncal skin rash which after biopsy was identified as being secondary to urticarial vasculitis (UV). Management consisted of oral methotrexate with discontinuation of previously initiated hydroxychloroquine (HCQ). While UV alone is not pathognomonic for lupus, patient-presentation both clinically and laboratory-wise favored systemic lupus erythematosus (SLE) (especially with presence of hypocomplementemia for C4) along with early rheumatoid arthritis(14.3.3η positivity), an overlapping condition also known as ‘rhupus’.