Photo Quiz

Purpura and Cough

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Am Fam Physician. 2014 Aug 1;90(3):181-182.

A 21-year-old man presented with fever, cough, arthralgias, and bilateral lower extremity rash and swelling that began 24 hours earlier. He had no history of asthma or seasonal allergies. He was not sexually active. He did not have a history of tick exposure or genitourinary symptoms.

On physical examination, he had a fever of 102°F (38.9°C) and a rash on both feet (Figures 1 and 2). The rash was erythematous, purpuric, and palpable. His white blood cell count was 10,500 per mm3 (10.5 × 109 per L) without eosinophilia. Platelet and red blood cell counts were normal. A urinalysis showed a trace amount of blood but no red blood cells, casts, or protein. Antineutrophil cytoplasmic antibody study results were negative. Chest radiography was performed (Figure 3).

Figure 1

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Figure 1

Figure 1

Figure 2

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Figure 2

Figure 2

Figure 3

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Figure 3

Figure 3


Based on the patient's history, physical examination, and radiography findings, which one of the following is the most likely diagnosis?

A. Churg-Strauss syndrome.

B. Erythema multiforme.

C. Erythema nodosum.

D. Leukocytoclastic (hypersensitivity) vasculitis.

Author disclosure: No relevant financial affiliations.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the U.S. government.

Address correspondence to Richard Temple, CDR, MC, USN, at Reprints are not available from the authors.


1. Habif TP. Clinical Dermatology. 5th ed. Edinburgh, Scotland: Mosby Elsevier; 2010.

2. Jennette JC, Falk RJ. Small-vessel vasculitis. N Engl J Med. 1997;337(21):1512–1523.

3. Sharma P, Sharma S, Baltaro R, Hurley J. Systemic vasculitis. Am Fam Physician. 2011;83(5):556–565.

4. Mansi IA, Opran A, Rosner F. ANCA-associated small-vessel vasculitis. Am Fam Physician. 2002;65(8):1615–1620.

5. Schwartz RA, Nervi SJ. Erythema nodosum: a sign of systemic disease. Am Fam Physician. 2007;75(5):695–700.

Contributing editor for Photo Quiz is John E. Delzell, Jr., MD, MSPH.

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