Presenter: Vukmer DO , Tyler O. Petrosian

Dermatology Program: Hackensack at Palisades UMC

Program Director: Ros DO FAOCD, Adriana

Submitted on: July 30, 2016

CHIEF COMPLAINT:  Pruritic, tender lesions on his lower legs

CLINICAL HISTORY: A 68-year-old Hispanic male presented complaining of a 2-year history of very pruritic, tender lesions on his lower legs. The patient also complained of a years-long history of arthralgia and asthma. Infectious disease treated suspected cellulitis with rocephin and vancomycin. There was no improvement in skin lesions.   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: aspirin 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.   Wegner’s Granulomatosis
2.   Polyarteritis Nodosa
3.   Deep Fungal Infection
4.   Eosinophilic Granulomatosis with Polyangiitis (EGPA)
5.   Stasis Dermatitis