A 34-Year-Old Woman With Knots on Her Leg and Reddening Skin

Padma Chitnavis, MD; Mary Maiberger, MD


May 19, 2023

Physical Examination and Workup

The patient is afebrile, with a temperature of 99.68°F (37.6°C). Her heart rate is 84 beats/min. Her respiratory rate is 12 breaths/min. Her blood pressure is 106/74 mm Hg. Her oxygen saturation is 97% on room air via pulse oximetry.

A physical examination is performed and is notable for several findings. Relating to her chief complaint, two red-to-purple, tender, indurated cords are observed on her right calf (Figure).


Also apparent on examination is a generalized, mottled, finely reticulated, violaceous discoloration of the skin on her arms, legs, and trunk. Punctuate to flame-shaped, subungual red markings can be appreciated on some of the nails of her hands and feet.

Inspection of the oral mucosa is revealing for an incidental finding of two, nontender, punched-out ulcerations on the hard palate and left buccal mucosa. She has no appreciable cervical, axillary, or inguinal lymphadenopathy.

No obvious abnormalities are appreciated on cardiovascular examination. Her respirations are not labored, and lung fields are clear to auscultation. Her abdomen is soft, nontender, and non-distended, with normal, active bowel sounds and no organomegaly.

Musculoskeletal examination is performed as well. Her right knee is mildly swollen and red, with range of motion only minimally limited due to pain. No other joint abnormalities are observed, despite her complaints. She has normal muscle bulk, tone, and strength.

Neurologic examination is largely unremarkable, with the exception of a mild, barely perceptible, facial asymmetry, which she reports having noticed suddenly a few months ago.

Venous duplex ultrasonography is performed and reveals the presence of a thrombus in the right leg, confirming the diagnosis of superficial thrombophlebitis. Radiography of the right knee shows no evidence of fracture, narrowing of the joint space, or articular degeneration.

Initial laboratory workup is performed. Complete blood count is significant for thrombocytopenia, elevated red cell distribution width, and a hypochromic, microcytic anemia with accompanying reticulocytosis and elevated serum lactate dehydrogenase. A comprehensive metabolic panel reveals no evidence of liver dysfunction but is revealing for an elevated serum creatinine level of 1.3 mg/dL. Coagulation studies demonstrate an abnormally prolonged activated partial thromboplastin time (aPTT). Blood cultures and a herpes viral culture of her oral lesions have been ordered and are pending. Antinuclear antibody (ANA) titers are abnormally elevated, with follow-up serologic studies pending.


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