with a 5-day history of dry cough, persistent dyspnea on exertion, and mild anterior chest pain on inspiration. She developed liquid diarrhea 5 times daily, 3 days prior to admission. A syncopal episode occurred the day of admission. Medical history revealed an overlap syndrome diagnosed 3 months earlier, systemic lupus erythematosus (SLE) with Raynaud phenomenon, arthritis, malar rash, alopecia, renal and lung involvement (interstitial lung disease [ILD] with nonspecific interstitial pneumonitis pattern), and dermatomyositis (DM) with heliotrope, Gottron papules, Gottron sign with some ulcers (Fig. 1), severe proximal muscle weakness, anemia, lymphopenia, antinuclear antibody positivity at 1/80, anti-dsDNA at 172.3 IU, elevated creatine phosphokinase, lactate dehydrogenase, aspartate aminotransferase, alanine aminotransferase, aldolase, and proteinuria at 3.5 g/day. High-resolution computed tomography of the chest revealed diffuse FIGURE 1. Clinical features at diagnosis. A and B, Gottron sign with ulcers in elbows and knees. C, Cutaneous vasculopathy in palms. E, Gottron papules in metacarpal phalanges.
