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Liver Palms (Palmar Erythema)

      A 48-year-old white woman presented with worsening fatigue, diffuse arthralgias, joint swelling, malaise, and icterus. In view of ongoing joint pains sparing the distal interphalangeal joints, early morning stiffness, strong family history of rheumatoid arthritis, positive rheumatoid factor, and a positive anti-cyclic citrullinated peptide antibody, she was recently diagnosed with rheumatoid arthritis. She had noticed a change in the color of her palms for about a year (Figure). She had no visible plantar erythema. There was no palpable hepatosplenomegaly, caput medusae, or ascites, with complete absence of other cutaneous signs of liver disease. Her liver function tests revealed hyperbilirubinemia, with a total bilirubin of 4.1 mg/dL, and elevated serum transaminases, with an alanine transaminase of 500 units/L and aspartate transaminase of 799 units/L. Her autoantibody profile revealed a positive antinuclear antibody with a titer of (1:640), with a positive anti-smooth muscle antibody titer (1:320), raising the concern for autoimmune hepatitis. She underwent a liver biopsy, which revealed moderately active hepatitis, predominantly acute, with features suggestive of transition to chronicity with bridging necrosis and early fibrosis.
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