“Look at my arm. It's all messed up,” opened our consultation with a twenty-eight-year-old woman. And we did look. What we saw was a left arm swollen to three times its size. We saw not only a hand, but a forearm and upper arm completely denuded of the outer skin. The entire limb was dusky red in color, and oozing clear fluid that dripped on the floor. Four physicians had seen her in the four weeks since it had all started. None could help despite intensive cortisone therapy and steroid salves. Day by day the problem had worsened.

This called for immediate hospitalization, for both therapy and diagnosis. Her history did not help. She had always been in perfect health. The only skin disease she had ever had was poison ivy dermatitis in her childhood.

We were worried that she had suffered a blood clot in her arm, but the vascular surgeons found nothing wrong. A Doppler study confirmed that she had normal circulation. Then began a circus of consultations and laboratory studies. During her three weeks in the hospital, she was seen by a parade of internists, anesthesiologists, and psychiatrists.

We kept the arm wrapped in compresses, and the anesthesiologists provided nerve blocks to improve circulation. The dermatitis gradually subsided and the arm became less swollen. But on day three, and again on day fifteen of hospitalization, we came in to find a huge soft purple swelling on the back of her left hand.