How would you approach this complex clinical presentation? We invite colleagues across all specialties to put on their diagnostic thinking caps and help unravel this intriguing case.

All suggestions are welcome, from medical students, interns, residents, registrars, consultants, or interested bystanders. Please send any suggested diagnoses or other comments to Marc Lanteri marc.lanteri@svha.org.au by 10am Monday 19th October. 

A 69 year old woman presented with a ten-day history of purpuric rash affecting the lower limbs, associated with itch. Past history included hypertension, hyperlipidaemia, and a three-pack-year history of previous smoking. Medications were Olmesartan, Dithiazide, Lercanidipine, Fenofibrate, Simvastatin, and Ezetimibe. She was born in South-East Asia, had migrated to Australia as a refugee three decades ago, and had worked in the garment industry.Physical examination revealed ankle oedema; subsequent trans-thoracic echocardiography demonstrated an ejection fraction of 60%.Biopsy of the rash was reported as consistent with urticaria; the rash subsequently resolved. Fever developed. Chest X-ray suggested left upper lobe changes, and CT scan was reported as consistent with possible haemorrhagic or inflammatory pathology.Blood tests demonstrated negative blood cultures, negative serology for HIV, Hepatitis B and C, and negative Quantiferon testing. C3 was 1.92 g/L, C4 was 0.51 g/L. Serum ACE was negative. ANA was positive at 1/2560, and anti dsDNA was also positive at 68 – later increasing to over 7,000.Bronchoscopy fluid testing was negative for AFB, mycobacterial PCR, and malignant cytology; 95% of cells were macrophages, ‘large’ growth of bacteria was detected. PET scan demonstrated a positive lesion in the left upper lobe of the lung with some lymph node positive signal, reported as consistent with chronic granulomatous disease.A diagnostic test was performed…

Light Lunch:                        12.15pm (please note no food to be taken into auditorium) 

Session Time:                    12.45pm

Date:                                     Monday 19th October 2026

Location:                             ACMD Auditorium & Microsoft Teams

Presenting Unit:               Clinicopathological Conference

Title:                                     “Like the Wolf on the Fold”

Chair:                                  Dr Marc Lanteri

Microsoft Teams meeting

Join: https://teams.microsoft.com/meet/41724192938760?p=gSDqHISr1gkb0knvWS

Meeting ID: 417 241 929 387 60

Passcode: MJ2hs2ya