Nirav Pavasia

Red Medicine MR

CaseC/C: My legs are in severe painHPI: Pt is a 38 yo BM w/ PMH of HTN, cocaine

abuser, presented to the ER w/ swelling and severe pain in both legs. Pt describes pain as sharp and burning, rates 10/10, tender to touch, non-radiating, associated w/ tightness, aggravated by movement and no relieving factors. Reports that the pain has been going on since 1 week but suddenly got worse last night and woke him up from sleep. Pt has not been able to ambulate 2/2 excruciating pain. Pt denies any similar episodes in the past. Pt has noticed subjective fevers and sweats for the past 2-3 days.Denies any trauma to the LE, recent travel, chest pain,

SOB, n/v, dizziness, lightheadedness, abdominal pain, change in bowel or bladder habbits, wt loss or wt gain.

ROS – Otherwise –ve unless stated per HPIPMH – HTNPSH – NoneFH – HTN, DMII, CADSH – smokes 1.5 ppd, >20 yrs; drinks 12pk

beer/day, >20 yrs; Snorts cocaine regularly – last use day before admission

VS

Temp: 38.3Pulse: 104BP: 169/95RR: 18O2 sat: 97% RA

Allergies – NKDAMeds – HCTZ

PEGen – WN, WD, in mild distress due to severe LE

painLE – skin hot to touch, shiny, tightness and TTP

in bilat LE, strength 3-4/5 due to pain, 4x5” palpable erythematic plaque like lesion in R calf, 2+ peripheral pulses bilat ext, no crepitus noted

HEENT – NC/AT, EOMI, PERRLA, dry oral mucosa, no LADP, no JVD

Chest – CTABL, no R/R/WCV – tachycardic, RRR, S1S2 nml, no M/R/GAbd – soft, NT, ND, NABS, no organomegalyNeurological – AAOx3, CN II-XII intact

LabsWBC – 24.8Hgb – 15Platelets – 198

PT – 14.6INR – 1.2PTT – 24.8

Na – 130K – 4.4Cl – 88CO2 – 30BUN – 19Cr – 1.0Gluc – 106Ca – 9.6

• CRP – 18• ESR – 19

• Urine – Cocaine Pos

Any thoughts?

DDxCellulitisDVTSuperficial ThrombophelbitisErysipelasGas gangreneNecrotizing Fasciitis

A/PCellulitis – bilateral?

Pt started on IV clindamycin, IV vancomycinblood cxGet US bilat LE to r/o DVTX-ray LE, CT LE w/ contrast to r/o gas

gangrene and/or necrotizing fasciitisIVF

Hospital coursePt continued to spike temperature for next 2

days, highest noted at 38.8US LE: -ve for DVTX-ray, CT LE: wnl, no evidence of soft tissue

edema, abscess, or gas noted. Normal limit LE w/o any pathology. No lymphedematous changes or any inflammatory changes were identified in either of the LE.

The erythamatous plaque like lesion in the R calf now beginning to spread in centrifuge fashion towards proximally and appeared in LLE as well around the ankle and toes.

Any thoughts?

DdxHenoch Schonlein Purpura (HSP)Hypersensitivity vasculitisWegener GranulomatosisChurg-Strauss Syndrome (Allergic

Granulomatosis)Polyarteritis nodosa Buerger Disease (Thromboangiitis Obliterans)Infective endocarditisThrombotic Thrombocytopenic PurpuraCocaine induced pseudovasculitisStevens-Johnson Syndrome and Toxic

Epidermal Necrolysis

Further work-upANA screen – negative w/ <1:40CXR, ACE levels to r/o sarcoidosis – CXR

unremarkable, ACE levels 59, CT chest – neg for hilar LADP or ILD

HIV Ab – negativeHepatitis panel – non-reactiveC3 – 151C4 – 37RPR – non-reactiveTTE – negative for valvular lesions; normal EF;

normal heart functionCPK – high at 351 then trended down to 126

Hospital CoursePt was evaluated by dermatology

service and Bx were takenPathology report verbal read - neutrophilic

infiltration around the small and medium size vessles showing leukocytoclastic vasculitis

ANCA work up – negativeBlood cx – negativePt fever controlled w/ tylenol, continued

to have severe 10/10 pain in LE, legs were less tight and shiny

Hospital coursePt was started on solu-medrol 70mg IV

per dermatology recsOver the course of 2-3 days pt’s pain

much improved, rated 3-4/10 and erythamatous lesions began to fade away

Vancomycin and Clindamycin stopped as WBC count normalized and pt afebrile for >3 days as well as clinical suspicion less likely for infectious etiology

PT/OT consult placed – pt began to ambulate slowly

Hospital courseRheumatology consult placed and…

Rheumatology recs - CryoglobulinHuman leukocyte elastaseLactoferrinCathespinLupus anticoagulantBeta-2 microglobulin3-2 glycoprotein

Hospital coursePt continued to improvePain subsided to 1-2/10 and pt switched to

PO steroidsPt was discharged home and was to follow

up as outpt in 2 weeks with rheumatology clinic

DdxCuatneous PAN (CPN)Hypersensitivity vasculitisCocaine induced pseudovasculitis

Thank you