Abrupt Rash with Painful, Nonpruritic Purpura on the Lower Extremities
Am Fam Physician. 2018 Nov 1;98(9):607-608.
An 80-year-old man presented with a painful rash on both lower extremities. The rash developed six hours after the patient took naproxen for chronic knee pain, and it progressed in an ascending fashion. The patient had a history of atrial fibrillation, chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and moderate osteoarthritis.
Physical examination revealed tender, nonblanching, nonpruritic purpura on the lower legs (Figure 1). Biopsy of the skin lesions showed neutrophilic infiltration of capillaries and venules, fibrin deposits, tissue necrosis, and extravasation of red blood cells.
Based on the patient's history, physical examination, and biopsy findings, which one of the following is the most likely diagnosis?
A. Cutaneous leukocytoclastic vasculitis.
B. Immune thrombocytopenic purpura.
C. Kaposi sarcoma.
D. Schamberg disease.
The answer is A: cutaneous leukocytoclastic vasculitis. Leukocytoclastic vasculitis is a small vessel vasculitis that is also known as hypersensitivity angiitis, drug-induced vasculitis, and hypersensitivity vasculitis.1 It is characterized by leukocytoclasis, a process of neutrophil infiltration, degranulation, and subsequent cell death that leads to the release of inflammatory mediators and vascular damage.1 Leukocytoclastic vasculitis may cause only cutaneous symptoms or may involve other organ systems such as the joints, kidneys, and gastrointestinal tract. It occurs equally in men and women and at any age.1
The classic presentation of cutaneous leukocytoclastic vasculitis includes nonblanching, nonpruritic, palpable purpura and petechiae on the legs or areas with tight-fitting clothing.2 Less common clinical findings include urticarial plaques, vesicles, bullae, pustules, and livedo reticularis.2 Leukocytoclastic vasculitis can be caused by medications, foods, infections, collagen-vascular
Referencesshow all references
1. Mackel SE, Jordon RE. Leukocytoclastic vasculitis. A cutaneous expression of immune complex disease. Arch Dermatol. 1982;118(5):296–301....
2. Leavitt RY, Fauci AS. Polyangiitis overlap syndrome. Classification and prospective clinical experience. Am J Med. 1986;81(1):79–85.
3. Aounallah A, Arouss A, Ghariani N, et al. Cutaneous leukocytoclastic vasculitis: about 85 cases [in French]. Pan Afr Med J. 2017;26138.
4. Martinez-Taboada VM, Blanco R, Garcia-Fuentes M, Rodriguez-Valverde V. Clinical features and outcome of 95 patients with hypersensitivity vasculitis. Am J Med. 1997;102(2):186–191.
5. Loricera J, González-Vela C, Blanco R, et al. Histopathologic differences between cutaneous vasculitis associated with severe bacterial infection and cutaneous vasculitis secondary to other causes: study of 52 patients. Clin Exp Rheumatol. 2016;34(3 suppl 97):S93–S97.
6. Cooper N, Bussel J. The pathogenesis of immune thrombocytopaenic purpura. Br J Haematol. 2006;133(4):364–374.
7. Vitale F, Briffa DV, Whitby D, et al. Kaposi's sarcoma herpes virus and Kaposi's sarcoma in the elderly populations of 3 Mediterranean islands. Int J Cancer. 2001;91(4):588–591.
8. Coulombe J, Jean SE, Hatami A, et al. Pigmented purpuric dermatosis: clinicopathologic characterization in a pediatric series. Pediatr Dermatol. 2015;32(3):358–362.
9. Hirschmann JV, Raugi GJ. Adult scurvy. J Am Acad Dermatol. 1999;41(6):895–906.
A collection of Photo Quizzes published in AFP is available at https://www.aafp.org/afp/photoquiz.
This series is coordinated by John E. Delzell Jr., MD, MSPH, Associate Medical Editor.
Previously published Photo Quizzes are now featured in a mobile app. Get more information at https://www.aafp.org/afp/apps.
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 http://www.aafp.org/afp/photoquizinfo. To be considered for publication, submissions must meet these guidelines. E-mail submissions to email@example.com.
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 firstname.lastname@example.org for copyright questions and/or permission requests.
Want to use this article elsewhere? Get Permissions