Photo Quiz

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.

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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.

E. Scurvy.


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

Address correspondence to Efren F. Wu, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show 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.

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