mockupThis story is a mockup. The patient shown is fictional, as is every date, result and document below.
The author's case
Almost a hundred medical documents — blood panels, urine analyses, magnetic-resonance scans, discharge summaries, fascial-biopsy histopathology, clinical photographs. Published here, redacted only where law requires (third-party data, identifying clinician details). This page is the index.
Published under Creative Commons Attribution-ShareAlike 4.0. Third-party data (other patients, family members, named clinicians where unconsented) is redacted; clinical content is otherwise unchanged.
96 docs
Total medical records released after redaction
38 panels
Blood-test panels archived (CBC, biochem, immunology)
14 scans
MRI sequences across four imaging studies (limbs, spine)
10 stays
Hospital discharge summaries, 2024 → 2026
/ how it started A swollen ankle
A swollen ankle
after a long walk, and seven months of being told it was nothing.
December 2023. Twenty-six years old, six months into my first IT job. My left ankle swelled after an evening walk — not a sprain, no injury, just a hard, board-like swelling that did not pit. I assumed it would resolve. It did not.
By February 2024 the swelling had crept up the calf and the skin of my forearms had begun to feel taut, as if I were wearing a tight long-sleeved shirt under my own skin. Range of motion at the wrists collapsed: I could no longer fold my hands in prayer position. A general practitioner suggested a fungal infection. An orthopaedist suggested overuse. A dermatologist suggested scleroderma and ordered an ANA panel — it came back negative, and the trail went cold.
What broke the diagnostic stalemate was a peripheral blood count from May 2024 showing absolute eosinophilia of roughly 2,200 / µL — well above the 500 / µL upper limit of normal. A rheumatologist at a tertiary centre saw the count alongside the skin findings, ordered an MRI of both forearms with T2-STIR and post-contrast sequences, and read the result herself: hyperintense thickening of the deep fascia with avid post-contrast enhancement. The full-thickness skin-to-muscle biopsy that followed two weeks later confirmed it — Shulman's eosinophilic fasciitis. ICD-10 M35.4.
Eight months from first symptom to diagnosis. That is faster than the literature average for this disease (median diagnostic delay in the published cohorts sits closer to 11 months, with a wide tail). It still felt like a year. This page exists so the next person does not have to walk that path blind.
Damian “Kuljo” Kuliś · Poznań · M35.4
/ diagnostic timeline
From first symptom to fourth line.
Eight steps between December 2023 and the present. Every step ties back to a specific document — discharge letter, biopsy report, blood panel, scan report — listed in the document index further down.
01
December 2023
First symptom
Unilateral, hard, non-pitting swelling of the left ankle after a long evening walk. No trauma, no fever, no rash. Self-resolution expected; none observed over six weeks.
02
February 2024
Spread, and the first three doctors
Symmetric forearm tightening, loss of wrist flexion, palpable induration of the calves. GP, orthopaedist and dermatologist seen sequentially over five weeks. Working diagnoses: fungal cellulitis, overuse strain, early scleroderma. ANA negative, anti-Scl-70 negative, anti-centromere negative.
03
May 2024
Peripheral eosinophilia of 2,200 / µL
Complete blood count ordered as part of a routine follow-up. Absolute eosinophil count flagged. Differential pivoted from connective-tissue disease towards an eosinophilic disorder. Referral to rheumatology accepted within two weeks.
04
July 2024
MRI of forearms and lower limbs
T2-STIR and post-contrast T1 sequences of both forearms and both calves. Reading rheumatologist documented hyperintensity and thickening of the deep fascia, with avid post-contrast enhancement — the imaging signature of fasciitis (Moulton 2005; Wright 2016). Muscle and subcutaneous tissue spared.
05
August 2024
Full-thickness fascial biopsy
Skin-to-muscle wedge biopsy of the right forearm under local anaesthesia, performed by an orthopaedic surgeon at a tertiary university hospital. Histopathology: thickened, inflamed fascia with a dense lymphoplasmacytic and eosinophilic infiltrate, sparing the dermis and the muscle. Diagnostic conference: eosinophilic fasciitis, ICD-10 M35.4.
06
August 2024 → March 2025
First line — oral prednisolone 1 mg/kg/day
Standard first-line therapy (Lakhanpal 1988, every subsequent cohort). Eosinophil count normalised within four weeks; skin tightening partially regressed. Taper attempt below 20 mg / day at month six provoked recurrence of forearm induration. Cumulative cushingoid features documented at month seven.
07
March 2025 → February 2026
Second and third lines — methotrexate, then mycophenolate
Subcutaneous methotrexate 20 mg / week added as a steroid-sparing agent (Wright 2016 evidence base). Partial response, transaminase elevation at month eight forced a switch to mycophenolate mofetil 2 g / day. Steroid taper achieved 7.5 mg / day maintenance.
08
March 2026 → present
Fourth line — rituximab off-label
Two 1 g infusions, two weeks apart (rheumatoid arthritis protocol applied off-label per published EF case series, e.g. Pinal-Fernandez 2014, Mango 2020). B-cell depletion confirmed at week 6. Forearm range of motion improving as of the most recent clinic visit. Status: active disease, ongoing.
/ laboratory gallery
Blood and urine, panel by panel.
Thirty-eight blood-test panels and seventeen urine analyses, redacted of name, date of birth and PESEL. Each tile links to the redacted PDF and to a brief plain-language interpretation. Reference ranges are the issuing laboratory's own.
Biochemistry — CRP, CK, ALT/AST
Immunoglobulins (IgG, IgA, IgM, IgE)
ANA / ENA / anti-Scl-70 panel — negative
Pre-treatment baseline
4-month prednisolone follow-up
Pre-methotrexate clearance panel
Transaminase elevation on MTX
MMF switch baseline
Pre-rituximab serology
Post-rituximab B-cell count (CD19)
24h urine collection — protein
The peak peripheral eosinophil count of ≈2,200 / µL (May 2024) is shown in the eosinophil-trend chart. Subsequent values reflect response to oral prednisolone, methotrexate, mycophenolate and rituximab in sequence.
/ imaging gallery
MRI, four studies, fourteen sequences.
Magnetic resonance imaging of both forearms (2024, 2025), both lower limbs (2024) and the lumbar spine (2025 — to rule out an alternative cause of leg stiffness). T2-STIR is the workhorse sequence for fasciitis. Post-contrast T1 confirms inflammatory enhancement. All images redacted of patient identifiers.
Forearms — T2-STIR, coronal
Forearms — post-contrast T1, axial
Lower limbs — T2-STIR, coronal
Lower limbs — post-contrast T1, axial
Forearms follow-up — T2-STIR, coronal
Lumbar spine — diagnostic exclusion
/ hospital discharges
Ten admissions, ten letters.
Each discharge summary is the formal record of an inpatient stay — admission reason, ward, length of stay, key findings, treatment delivered, discharge plan. Reading the ten letters in order is the fastest way to reconstruct the disease course.
01
Rheumatology 8 days
Diagnostic admission
Fascial biopsy of the right forearm, full diagnostic work-up, initiation of oral prednisolone 1 mg/kg/day. Histopathology confirmed eosinophilic fasciitis.
02
Rheumatology 5 days
First IV methylprednisolone pulse cycle
Methylprednisolone 1 g IV × 3 days as a bridging treatment alongside oral prednisolone. No adverse events. Eosinophil count maintained within normal range.
03
Rheumatology 4 days
Methotrexate initiation
Subcutaneous methotrexate 15 mg/week started under inpatient observation; folic-acid supplementation; baseline LFTs documented.
04
Internal medicine 3 days
Transaminase elevation on MTX
ALT 184 U/L, AST 142 U/L. Methotrexate paused; hepatology consult; viral hepatitis serology negative; resolution within 14 days. Decision to switch to mycophenolate.
05
Rheumatology 4 days
Mycophenolate mofetil initiation
MMF 1 g BID started inpatient. Baseline serology, CMV-PCR negative. Prednisolone taper continued to 7.5 mg/day.
06
Physiotherapy day-ward 10 days (day)
Rehabilitation cycle
Day-hospital physiotherapy programme for joint contracture maintenance — passive range-of-motion, aquatic therapy, ultrasound. Discharge with home exercise plan.
07
Rheumatology 2 days
Disease-activity reassessment
Clinical examination, MRI re-imaging, decision conference. Recurrence of forearm induration despite MMF + steroid maintenance. Plan: switch to rituximab.
08
Internal medicine — biologics day-unit 1 day
Rituximab infusion 1
Rituximab 1 g IV with standard premedication (paracetamol, antihistamine, methylprednisolone 100 mg IV). Infusion tolerated; no reaction. Observation 4 h post-infusion.
09
Internal medicine — biologics day-unit 1 day
Rituximab infusion 2
Second rituximab 1 g IV two weeks after the first. Uneventful infusion. CD19 B-cell count to be checked at week 6.
10
Rheumatology 3 days
Six-week post-rituximab assessment
B-cell depletion confirmed (CD19 < 1 %). Forearm range of motion improving on clinical examination. Continued MMF and low-dose prednisolone. Next reassessment scheduled for autumn 2026.
/ clinical photography
Six photographs, two years.
Standardised clinical photographs taken at home with consistent lighting and pose. They are not diagnostic — they document the visible course of the disease: the groove sign on the forearms, the prayer-sign deficit, the puckered orange-peel skin of the calves at peak disease, and the partial reversal under treatment.
/ treatment ladder
Four lines, in the order they were tried.
Eosinophilic fasciitis has no licensed therapy. Practice is reconstructed from cohort studies and case series — first-line glucocorticoids, methotrexate as the most-used steroid-sparer, mycophenolate or rituximab as later steps. This is the order applied here, with documented outcomes.
I
Oral prednisolone 1 mg/kg/day, tapered
drug class Glucocorticoid
period Aug 2024 → present (maintenance)
Eosinophil count normalised at week 4. Skin tightening regressed ~50 % at month 6. Taper below 20 mg/day provoked recurrence at month 6.
II
Methotrexate 20 mg/week subcutaneous
drug class DMARD — folate antagonist
period Mar 2025 → Oct 2025
Partial steroid-sparing effect. Transaminase rise (ALT 184) at month 6 forced discontinuation.
III
Mycophenolate mofetil 2 g/day
drug class DMARD — IMPDH inhibitor
period Oct 2025 → present (maintenance)
Tolerated. Allowed prednisolone taper to 7.5 mg/day. Disease activity stable for ~4 months then recurred.
IV
Rituximab 1 g × 2 infusions, off-label
drug class Anti-CD20 monoclonal antibody
period Mar 2026 → ongoing
B-cell depletion confirmed. Early clinical improvement at week 6. Reassessment planned at month 6.
/ document index
Browse every record.
The full inventory of records released for publication, grouped by document type. Each category links to its own redacted PDF archive. Filenames follow the convention CATEGORY-YYYY-MM-CODE so that documents can be cross-referenced from any other page on this site.
38
Blood-test panels
CBC + differential, biochemistry, immunology, immunoglobulin levels, ANA / ENA / anti-Scl-70 series, CRP / ESR longitudinal trend, CK / aldolase, drug-monitoring panels.
17
Urine analyses
General urinalysis, 24-hour protein collections during MMF, urine cultures during admissions, drug-monitoring side-effect surveillance.
14
MRI sequences
T2-STIR, post-contrast T1, axial / coronal / sagittal cuts of forearms, lower limbs and lumbar spine across four studies (2024 × 2, 2025 × 2).
1
Fascial biopsy report
Full histopathology report of the August 2024 right-forearm wedge biopsy: thickened fascia, dense lymphoplasmacytic + eosinophilic infiltrate, dermis and muscle spared.
10
Hospital discharge summaries
Formal discharge letters from each inpatient stay 2024 → 2026, listed above in the discharges section with their reasons and findings.
12
Outpatient clinic letters
Letters from rheumatology, dermatology, hepatology and internal-medicine clinic visits — diagnostic working hypotheses, management plans, prescription rationale.
6
Clinical photographs
Self-taken, standardised photographs documenting groove sign, prayer-sign deficit, peau d'orange induration and the partial reversal under treatment.
5
Other records
ECG strips (pre-pulse-steroid baseline), bone-densitometry on long-term glucocorticoid use, ophthalmology screening, vaccination record before rituximab.
All documents are released under CC BY-SA 4.0 with third-party data, named clinicians and identifying patient data redacted. PESEL number, full name and date of birth are blacked out on every page.
/ reflection Publishing my own case is the price of
Publishing my own case is the price of
asking other patients to publish theirs.
There are perhaps thirty published case series of eosinophilic fasciitis in the global literature, totalling around three hundred cases — for a disease that has existed clinically since Shulman described it in 1974. The reason is not that patients are rare; the reason is that case data is hard to publish, hard to share, hard to redact, hard to defend legally. So the data sits in hospital archives and dies there.
This page is the simplest fix I could think of. One patient, one full record, one persistent web page. If even one of the next hundred patients gets diagnosed faster because their rheumatologist read this, the work is paid for.
— D. K., author
If you read something here that contradicts a published source, or if your own case differs in a useful way, the contact form is open.
/ mockup
This patient story is a mockup
What you see below is only a mockup — a preview of how an individual patient's story might look in the future.
It does not describe a real person. The patient shown here is fictional, and so is every date, result, document and image on the page.
Nothing on this page is a medical record, and nothing on it is medical advice.
Tick the box above to unlock the story.