YOU DON'T WANT TO MISS THIS RASH K Peakock MD, JL Taggart DO Department of Medicine, Tulane Health Sciences Center, New Orleans, LA INTRODUCTION Development of purpuric rash acutely while hospitalized is uncommon and presents a diagnostic challenge to internists. Purpuric rashes, or lesions that do not blanch with pressure or diascopy, indicate vascular damage or vessel wall inflammation. Two mechanisms for vascular infiltration include direct invasion by infectious pathogen or immune- mediated inflammation. CASE: A 61-year-old man was admitted for surgical resection of left fifth metatarsal due to osteomyelitis refractory to antibiotic treatment. Admission vital signs were within normal limits and laboratory findings showed ESR 79 mm/hg, CRP 7.07 mg/dL, and WBC 9.2 k/uL. Initial treatment included vancomycin and cefepime followed by surgical debridement and amputation. On postoperative day 4, he developed a painful, palpable maculo-papular purpuric rash primarily on the posterior calves, with fewer lesions on the dorsum of the hands, and sparing the palms and soles. There were no acute changes in vital signs, complete blood count or serum chemistries, and HIV and hepatitis C were non-reactive. Antibiotics were held. Dermatology consultants performed bedside exam and biopsy. Rash improved with topical clobetasol 0.05%. Antibiotics were adjusted to doxycycline monotherapy. Biopsy results revealed superficial and deep perivascular neutrophilic infiltrate with focal fibrinoid degeneration, extravasated erythrocytes, and occasional eosinophils, consistent with leukocytoclastic vasculitis (LCV). Topical steroids were continued for symptom relief. DISCUSSION: LCV or cutaneous small-vessel vasculitis, refers to infiltration of neutrophils into blood vessel walls in response to drug exposure, hepatitis C virus, or autoimmune connective tissue disease, although most cases are idiopathic. Findings will be circular lesions, primarily in dependent areas, with biopsy showing abundant neutrophils with little or no immunoglobulin. Treatment centers on detecting or ruling out underlying causes and correcting them, with topical steroids for symptom relief. Due to the life-threatening differential for purpuric lesions, you don’t want to MISS this RAsH (Meningococcemia, ITP, Septic vasculitis, Sweet syndrome, Rocky Mountain spotted fever, Autoimmune, or HSP).
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