A 70 year old recent Russian female emigrant was admitted to our ward with a deep venous thrombosis of the left femoral vein. She reported a four year history of seronegative “rheumatoid arthritis” (RA). She also had symmetrical, shiny, smooth, firm, and spherical papules and nodules of waxy colour that coalesced to form band-like lesions on her face (fig 1). These lesions started one year before admission and progressed over time. Her tongue was diffusely enlarged.

   Examination of her joints disclosed synovial swelling and tenderness of both wrists (fig 2), with …