A 20-Year-Old Man With a Dark, Burning Rash

Christian Beebe, MD, MBA

Disclosures

August 13, 2015

Physical Examination and Workup

On physical examination, the patient has a strong pulse, with a regular heart rhythm and rate of 58 beats/min, blood pressure of 123/60 mm Hg, weight of 165.3 lb, and oral temperature of 98.1°F. He is a very fit, well-developed white male in no apparent distress. The pharynx shows no erythema or exudate, and the neck examination demonstrates no tenderness to palpation or lymphadenopathy. The cardiac examination is notable for a point of maximum intensity at the fifth left interspace, but no murmurs, gallops, or rubs are heard.

Figure 1.

Figure 2.

Figure 3.

The patient's pulses are strong bilaterally. The respiratory examination reveals lungs that are clear to auscultation bilaterally. The abdominal examination is unremarkable, and the stool test is negative for occult blood.

Skin examination shows lesions ranging in diameter from 2 mm to 10 cm (Figures 1-3). The macules and plaques do not blanch upon pressure, and most of them are concentrated in the posterior calves, the palms, and the soles of the feet. No macules or plaques are noted on the face, chest, or back. The lesions are not tender to palpation or warm to the touch. His hands and right ankle exhibit 1+ nonpitting edema.

The patient has a scar on his right leg from his motorcycle accident that is well-healed, with no fluctuance or erythema. The neurologic examination is unremarkable.

A random urinalysis shows dipstick evidence of both 2+ protein and 2+ blood, with 25-50 red blood cells per high-power field on microscopy. His coagulation studies at admission include a prothrombin time of 12.3 sec, an international normalized ratio of 1.08, and a partial thromboplastin time of 25.5 sec.

The patient's blood urea nitrogen is 24 mg/dL, and his creatinine value is 1.1 mg/dL. The complete blood count shows a white blood cell count of 7.4 × 103 cells/µL, a hemoglobin of 12.4 g/dL, a hematocrit of 37.1%, and a platelet count of 195 × 103 cells/µL, with a normal smear.

Skin-punch biopsies of two of the lesions are obtained that demonstrate small-vessel leukocytoclastic vasculitis. Immunofluorescence of the skin biopsy samples demonstrates a weak linear pattern at the dermal/epidermal junction for immunoglobulin G (IgG) and a slightly stronger linear pattern for both immunoglobulin A (IgA) and complement 3 (C3).

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