Pruritic, tender lesions on lower legs

Presenter: Vukmer DO PGY3, Tyler O. Petrosian OMGE 4, Serge
Dermatology Program: Hackensack at Palisades UMC
Program Director: Ros DO FAOCD, Adriana
Submitted on: Jul 30, 2016

CHIEF COMPLAINT:  A 68 year-old hispanic male presented complaining of a 2 year history of very pruritic, tender lesions on his lower legs.

CLINICAL HISTORY:

Signs and symptoms:  The patient also complained of a years long history of arthralgia and asthma.

Previous Treatment:  Infectious disease treated suspected cellulitis with recephin and vancomycin. There was not improvement in the skin lesions.

Other information:  Family history was positive for asthma, arthritis, diabetes, and thyroid disorders. The only medical allergy was to percocet.
Medications at the time of presentation were: aspitin 81mg po qd, levothyroxine 25mcg po qd, lovastatin 10mg po qd, metoprolol 50mg po qd, and montelukast 10mg po qd.

PHYSICAL EXAM:

Six to ten tender, erythematous, red-brown papules and plaques, some with central ulceration, located on the medial aspect of the distal lower extremities bilaterally.

 

 

 

LABORATORY TESTS:

Creatinine 1.35, e-GFR 53, absolute eosinophil count 1033
ANCA positive at 1:80, atypical pattern
ANA, ASO, ESR, Anti-SSa/SSB – all WNL.
Myeloperoxidase IgG – WNL

DERMATOHISTOPATHOLOGY:

Medium vessel vasculitis – Note: a relatively circumscribed vessel infiltrated and surrounded by fibrin and nuclear dust, suggesting Polyarteritis Nodosa. However, the presence of necrosis extending into the subcutaneous tissue would be concerning for a nodular vasculitis.

DIFFERENTIAL DIAGNOSIS:

1.   Wegners Granulomatosis
2.   Polyarteritis Nodosa
3.   Deep Fungal Infection
4.   Eosinophilic Granulomatosis with Polyangitis (EGPA)
5.   Stasis Dermatitis


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