The patient was a 15-year-old male adolescent with painful and pruritic erythematous indurated nodules on his legs and hands that progressed to ulcerated lesions over 1 month (figure 1). The patient had medical history of juvenile idiopathic arthritis, hypothyroidism and hyperphosphatemia. He was treated with prednisolone, methotrexate, levothyroxine and sevelamer carbonate. Laboratory tests (complete blood count, biochemical tests, blood complement level, liver function tests, renal function tests) were within the normal limits except an elevated C reactive protein (53 mg/L, normal range <6 mg/L), erythrocyte sedimentation rate (25mm/hour, normal range 0-10mm/hour) and serum phosphorus level (9.3mg/dL, normal range 2.9-5.1 mg/ dL).
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