Hidden in Plain Sight: Eosinophilic Fasciitis

      A 66-year-old woman complained of gradual swelling and hardening of the skin of all limbs over 2 months, which started distally in the legs and progressed upward, symmetrically, and was associated with difficulties in function and a weight gain of 10%. Examination was notable for diffuse marked limb edema (mostly nonpitting) and hardening of the skin with prominent peau d'orange appearance of the cubital fossa (Figures 1A and 1B). The examination was otherwise normal. Her past history included obesity, diabetes and dyslipidemia treated with empagliflozin and atorvastatin. When blood count revealed eosinophilia (absolute count 3270, normal hemoglobin and platelets) she was admitted to a teaching hospital.
      Figure 1
      Figure 1(A) “Peau d'orange” appearance of the patient's cubital fossa. Note proximal and distal swelling (and hardening) of the upper limb. (B) Swelling and hardening of the skin of the lower legs, with both pitting and nonpitting edema.
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