In this slideshow, you can learn about different presentations of vasculitis. Each slide links to the full case report for more details.
Vasculitis Presenting as Calf Pain With Muscle-Limited Involvement
A 37-year-old woman with no significant medical history was referred to the rheumatology clinic by her primary care provider for unexplained right calf pain and elevated inflammatory markers. She described the pain as sharp and stabbing, which worsened with activity. She also reported intermittent swelling of the lower part of the leg, which also was tender to the touch.
At her earlier primary care visit, findings of a review of systems were negative for any constitutional, cardiopulmonary, gastrointestinal, or neurological complaints. Vital signs were normal. Physical examination revealed a shiny and taut appearance to the right lower extremity with exquisite tenderness to palpation to the musculature of the calf.
Palisaded Neutrophilic Granulomatous Dermatitis with Concomitant Leukocytoclastic Vasculitis: A Spectrum of a Rare Disease
A 55-year-old woman was referred to a dermatology practice for a cutaneous eruption over the elbows and posterior thighs of one month’s duration. The affected areas had been intensely pruritic, with minimal improvement with the use of diphenhydramine. She had a 15-year history of worsening rheumatoid arthritis (RA), which was being managed with oral prednisone and oxycodone-acetaminophen.
Physical examination revealed several nontender skin-colored to erythematous papules with peripheral scale on the extensor surface of the bilateral elbows. Nonblanching, nontender, well-defined, annular purpuric papules and coalesced plaques were present on the posterior thighs.
A punch biopsy of a lesion on the left arm demonstrated palisaded neutrophilic granulomatous dermatitis, and a punch biopsy of a lesion on the right thigh demonstrated small vessel vasculitis (Figure).
Vasculitis Masquerading as an Infection
A 74-year-old female with a history of polymyalgia rheumatica and hypertension presented with bilateral foot and hand rash that developed over two days. Patient recalled being in a wooded area 4 days prior. The rash is associated with pain and burning in the dorsum of both feet. Patient initially took antihistamines with no improvement. She came to the emergency department the next day as the erythema progressed to her hands and became more pronounced on the feet.
On physical examination, patient’s vitals were within normal range. Her extremities were significant for bilateral non-blanching, tender, foot violaceous rash extending above the ankles and bullae lesions over the medial aspect of the heels bilaterally (Figure). The palms revealed a diffuse petechial rash that was less pronounced than that of the lower extremities.
Trimethoprim-Sulfamethoxazole-Induced Leukocytoclastic Vasculitis
A 22-year-old Hispanic male inmate with no remarkable past medical or social history presented to our hospital with a persistent, diffuse, erythematous eruption.
Approximately 1 year prior to admission he was evaluated for pustules on the posterior scalp diagnosed as acne. The lesions persisted into keloidal acne after months. Roughly 2 weeks prior to presentation, a unit healthcare evaluated the patient and prescribed trimethoprim-sulfamethoxazole (TMP-SMX) 480 mg twice daily for the pustules on his scalp.
Two days after being prescribed TMP-SMX, the patient developed a painful and pruritic papular eruption to his calves. Over the following week, the lesions on his calves developed into erythematous bullae and new erythematous papules erupted on his abdomen, thighs, and arms. The unit provider subsequently discontinued the antibiotic.
Leukocytoclastic Vasculitis: A Marker of Underlying Malignancy
A 62-year-old man presents with a violaceous, nonpruritic eruption that arose 2 weeks earlier on the hands and feet, including the palms and soles, and spread to the arms and legs (Figure). Over the past 3 to 4 weeks, he has had malaise, nonproductive cough, and a decline in mental status but no fever, headache, nausea, light-headedness, hemoptysis, or melena.
Slideshow: Presentations of Vasculitis