Dermatologic Diagnosis: Leukocytoclastic Vasculitis

Leukocytoclastic Vasculitis Masquerading as Chronic Idiopathic Thrombocytopenic Purpura

Background

Idiopathic thrombocytopenic purpura and leukocytoclastic vasculitis can present in a similar fashion and can be very hard to differentiate clinically without a biopsy. This can cause diagnostic dilemma and delay in management. A thorough evaluation is recommended to determine etiology, although about half are idiopathic.

Case Presentation

A patient aged 79 years with longstanding thrombocytopenia secondary to chronic idiopathic thrombocytopenic purpura presented with a rash. Although it was thought to be secondary to idiopathic thrombocytopenic purpura, a biopsy revealed presence of leukocytoclastic vasculitis.

Conclusions

Although most leukocytoclastic vasculitis cases are mild and resolve without intervention, many go undiagnosed due to biopsy delays. Health care professionals should determine and treat the underlying cause.

Leukocytoclastic Vasculitis as the Presenting Symptom of Crohn's Disease in an Adolescent

Leukocytoclastic vasculitis (LCV) is a rare vascular inflammatory condition that affects post-capillary venules. Its incidence in the pediatric population is unknown. However, its incidence has been shown to increase with age. The causes of LCV can be varied, ranging from drugs to infections to systemic disease. LCV as a presenting symptom of inflammatory bowel disease (IBD) is rare, especially in the pediatric population. A 15-year-old female with a family history of systemic lupus erythematosus was transferred to our hospital with a month-long history of rash, joint swelling and tenderness, periorbital edema, weight loss, and diarrhea. She presented with the objective findings of a biopsy showing LCV and a computed tomography scan read that was concerning for IBD versus infectious colitis. She had a thorough workup, involving both the rheumatology and gastroenterology services, and was ultimately found to have Crohn’s disease. This case reveals the importance of recognition of a constellation of symptoms in IBD even when they are not classical in nature at initial presentation.

Iodine Contrast Complex Rash Responding to Topical Steroids: A Case Report

Patient: Male, 75-year-old

Final Diagnosis: Delayed IV contrast allergic reaction

Symptoms: Rash

Medication:—

Clinical Procedure: —

Specialty: Dermatology

Leukocytoclastic vasculitis associated with sorafenib treatment for hepatocellular carcinoma

Small-vessel vasculitis is an uncommon diagnosis associated with many causes, including certain medication. Characteristic findings are immune complex deposition, vessel wall damage, and erythrocyte extravasation. We present a case of a 77-year-old man with advanced hepatocellular carcinoma who was treated with sorafenib. Twenty days post introduction to sorafenib, the patient experienced high fever and painful purpura on the lower limbs. The results of the skin biopsy confirmed the diagnosis. More extensive diagnostics was undertaken, which excluded other possible causes of vasculitis and infectious disease. Following a full recovery, after the steroid treatment was completed, sorafenib has been continued until the progression of the carcinoma. This is the second described case of hepatocellular carcinoma associated with sorafenib treatment and leukocytoclastic vasculitis. Sorafenib is a potential cause of vasculitis, and clinicians should bear in mind to differentiate it from hand-foot skin reaction, which is a common side effect of multikinase inhibitors. The result of our assessment is important considering that vasculitis requires more specific diagnostic procedures, treatment, and often drug discontinuation.

Impending central retinal vein occlusion in patient with idiopathic cutaneous leukocytoclastic vasculitis

Purpose

To report a case of impending central retinal vein occlusion (CRVO) associated with idiopathic cutaneous leukocytoclastic vasculitis (LCV) that demonstrated significant resolution following treatment with intravenous (IV) methylprednisolone.

Observations

A 27-year-old man presented to a tertiary Uveitis Clinic with a five-day history of blurry vision in the right eye (OD). He had a history of a purpuric rash and arthralgias five years ago and a biopsy-confirmed diagnosis of LCV controlled with colchicine two years ago in India. Recently, he presented with a recurrent rash and severe abdominal pain. After being evaluated by rheumatology and gastroenterology, he was placed on Helicobacter pylori treatment and high dose oral prednisone, which improved his skin and gastrointestinal symptoms. At the first ophthalmic exam, his systemic findings included lower extremity purpura. His best-corrected visual acuity (BCVA) was 20/20 in both eyes (OU). Slit-lamp examination revealed no cells or flare in OU. Dilated fundus exam showed mild enlarged, tortuous veins, optic nerve hemorrhage, and intraretinal hemorrhages temporal to the macula in OD. Spectral-domain optical coherence tomography (SD-OCT) demonstrated multiple hyper-reflective, plaque-like lesions involving the inner nuclear layer, consistent with paracentral acute middle maculopathy (PAMM). The patient was diagnosed with impending central retinal vein occlusion (CRVO) in OD. Laboratory evaluations were unremarkable. Aspirin was initially started for the patient but was later held due to the worsening of retinal hemorrhage and retinal vein tortuosity at the one-week follow-up. The patient then received three doses of intravenous methylprednisolone, followed by systemic oral prednisone and mycophenolate mofetil. One month later, retinal hemorrhages, venous stasis, and skin manifestations resolved.

Conclusion and importance

Ocular involvement in LCV is rare and may present with different manifestations. The index case is the first report of impending CRVO in a patient with idiopathic LCV and without any other known risk factors for CRVO. Our report not only describes the unique course of LCV-related ocular involvement, but also introduces and underscores a potentially effective therapeutic plan.

Early diagnosis and treatment of Leukocytoclastic Vasculitis: case report

A 46-year-old female patient presented at the emergency department of a Municipal University Hospital with necrotic lesions in lower limbs associated with wasting syndrome. She was diagnosed with leukocytoclastic vasculitis after physical examination and history-taking in a fast and cost-effective manner, using an algorithm specifically for primary vasculitis, enabling early and appropriate treatment. The good clinical outcome demonstrates the need to quickly make a definitive diagnosis and start treatment.

Colloidal Silver Ingestion Associated with Leukocytoclastic Vasculitis in an Adolescent Female

Patient: Female, 19

Final Diagnosis: Leukocytoclastic vasculitis

Symptoms: Fatigue • joint • pain • muscle • pain • pruritis • rash

Medication: —

Clinical Procedure: —

Specialty: Dermatology

Leukocytoclastic vasculitis caused by hepatitis C virus in a liver transplant recipient: A case report

BACKGROUND

Infection by the hepatitis C virus (HCV) is currently considered to be a global health issue, with a high worldwide prevalence and causing chronic disease in afflicted individuals. The disease largely involves the liver but it can affect other organs, including the skin. While leukocytoclastic vasculitis has been reported as one of the dermatologic manifestations of HCV infection, there are no reports of this condition as the first symptom of HCV recurrence after liver transplantation.

CASE SUMMARY

We report here a case of leukocytoclastic vasculitis in a liver transplant recipient on maintenance immunosuppression. The condition presented as a palpable purpura in both lower extremities. Blood and urine cultures were negative and all biochemical tests were normal, excepting evidence of anemia and hypocomplementemia. Imaging examination by computed tomography showed a small volume of ascites, diffuse thickening of bowel walls, and a small bilateral pleural effusion. Skin biopsy showed leukocytoclasia and fibrinoid necrosis. Liver biopsy was suggestive of HCV recurrence in the graft, and HCV polymerase chain reaction yielded 11460 copies/mL and identified the genotype as 1A. Treatment of the virus with a 12-wk direct-acting antiviral regimen of ribavirin, sofosbuvir and daclatasvir led to regression of the symptoms within the first 10 d and subsequent complete resolution of the symptoms.

CONCLUSION

This case highlights the difficulties of diagnosing skin lesions caused by HCV infection in immunosuppressed patients.

Vasculitis of small and large vessels, a casual association?

The authors report a case of a 69-year-old man with idiopathic leukocytoclastic cutaneous vasculitis. For three years, the lesions recurred with progressive worsening and were associated with systemic manifestations of low-grade fever, weight loss and raised inflammatory markers. The patient latter presented a 6th cranial nerve involvement, raising the concern of a possible systemic vasculitis, which was latter evidenced by the development of deep vein thrombosis and angina pectoris. The treatment of the patient witch based on the decreasing of inflammatory activity, by using effective immunosuppressive therapy, with lower toxicity is more important than identifying the type of the vasculitis. This case illustrates the importance of awareness for the systemic involvement that can occur in up to 50% of patients with leukocytoclastic cutaneous vasculitis.

Childhood systemic vasculitis

Vasculitides are characterized by inflammation of the vessel wall. Most of the vasculitides tend to occur in vessels of a specific size and certain target organs. In this review, we discuss each specific childhood vasculitis according to the latest Chapel Hill Consensus Conference 2012 nomenclature system and the Ankara 2008 classification criteria. We have also reviewed the clinical and laboratory characteristics and the recent treatment recommendations for the vasculitides we encounter in children.

A not-so-sweet diagnosis - leukocytoclastic vasculitis masquerading as squamous cell carcinoma

Leukocytoclastic vasculitis (LCV) is a rare small-vessel vasculitis characterised by neutrophilic inflammation of post-capillary venules. Incidence varies from 3 to 4.5 per 100 000 people per year. Patients typically present with painful, itchy purpura and erythema, although clinical manifestations can vary making diagnosis a challenge. We report the case of a 75-year-old man with a history of a previously completely excised and grafted squamous cell carcinoma (SCC) on the dorsum of his hand, who presented with an acutely swollen, erythematous and ulcerated lesion adjacent to the graft site. A shave biopsy failed to definitively exclude SCC recurrence. He was referred to the Plastics team who initially suspected Sweet's syndrome but could not rule out SCC recurrence. The patient underwent formal mapping incisional biopsies that later diagnosed LCV. He was managed conservatively and made an excellent recovery. We present clinical photographs and histology to illustrate disease progression. LCV is typically self-limiting with a good overall prognosis, but a minority of patients follow a protracted course, which may require treatment in the form of systemic corticosteroids or colchicine. LCV can only be confirmed histologically. We present this case in order to highlight the importance of adequate tissue biopsy when there is diagnostic uncertainty with an acute dermatosis, particularly in the context of previous skin malignancy.