Photo Quiz

Lower Extremity Erythema


Am Fam Physician. 2018 Jul 15;98(2):107-108.

A 69-year-old man and self-described hermit presented with erythema on his left leg. He was prescribed a seven-day course of trimethoprim/sulfamethoxazole for suspected cellulitis. A lower extremity venous duplex scan was negative for deep venous thrombosis. He presented to the emergency department one week later with spreading erythema and increased pain on weight bearing. He had new petechiae on his right lower extremity. He had a history of tobacco use, long-term daily alcohol use, and hypertension.

Physical examination revealed an open eschar over the left medial malleolus (Figure 1). There was no fluctuance, crepitus, or warmth. Posterior tibial pulses were weak but present on Doppler ultrasonography. Capillary refill was normal. Laboratory workup was notable for chronic iron deficiency anemia and an international normalized ratio of 1.4 without anticoagulation. An arterial duplex scan showed complete occlusion of the midanterior and distal anterior tibial artery. Magnetic resonance imaging showed intramuscular lesions consistent with chronic fibrosis from ischemia. Lower extremity punch biopsies were conducted to assist with diagnosis. Pathology showed perifollicular hemorrhage.

 Enlarge     Print




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

A. Cellulitis refractory to treatment.

B. Ischemia due to peripheral artery disease.

C. Necrotizing fasciitis.

D. Small vessel vasculitis.

E. Vitamin C deficiency (scurvy).


The answer is E: vitamin C deficiency (scurvy). A diagnostic punch biopsy demonstrated perifollicular hemorrhage consistent with scurvy. Low vitamin C levels predicate decreased synthesis of collagen, which allows for the breakdown of connective tissue, followed by the development of erythema, necrotic areas, and anemia. Many patients with scurvy have eschars.1,2 Because of his isolated lifestyle, the patient may have other nutrient deficiencies.

Cellulitis presents as skin breakdown followed by unilateral painful erythema that is warm to the touch. It is typically associated with induration, fluctuance, or drainage. Cellulitis often leads to systemic symptoms such as fevers, chills, or tachycardia, especially with failed outpatient therapy.3

The patient had pulses on Doppler ultrasonography and adequate capillary refill, which rules out acute ischemia. Despite the eschar,

Address correspondence to Theodore Demetriou, DO, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Léger D. Scurvy: reemergence of nutritional deficiencies. Can Fam Physician. 2008;54(10):1403–1406....

2. Mutgi KA, Ghahramani G, Wanat K, Ciliberto H. Perifollicular petechiae and easy bruising. J Fam Pract. 2016;65(12):927–930.

3. Hook EW III, Hooton TM, Horton CA, Coyle MB, Ramsey PG, Turck M. Microbiologic evaluation of cutaneous cellulitis in adults. Arch Intern Med. 1986;146(2):295–297.

4. Townsend CM Jr., Beauchamp RD, Evers BM, Mattox KL. Sabiston Textbook of Surgery: The Biological Basis of Modern Surgical Practice. 20th ed. Philadelphia, Pa.: Elsevier; 2017.

5. Mandell GL, Douglas RG, Bennett JE, Dolin R, Blaser MJ. Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases. 8th ed. New York, NY: Elsevier; 2015.

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

This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.

A collection of Photo Quiz published in AFP is available at

Previously published Photo Quizzes are now featured in a mobile app. Get more information at

The editors of AFP welcome submissions for Photo Quiz. Guidelines for preparing and submitting a Photo Quiz manuscript can be found in the Authors' Guide at To be considered for publication, submissions must meet these guidelines. E-mail submissions to



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Jun 15, 2019

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article