Red Medicine MR
Nirav Pavasia
Case
 C/C: My legs are in severe pain
 HPI: 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, nonradiating, 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 HPI
 PMH – HTN
 PSH – None
 FH – HTN, DMII, CAD
 SH – smokes 1.5 ppd, >20 yrs; drinks 12pk beer/day, >20
yrs; Snorts cocaine regularly – last use day before admission
VS
 Temp: 38.3
 Pulse: 104
 BP: 169/95
 RR: 18
 O2 sat: 97% RA
 Allergies – NKDA
 Meds – HCTZ
PE
 Gen – WN, WD, in mild distress due to severe LE pain
 LE – skin hot to touch, shiny, tightness and TTP in bilat LE,
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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/W
CV – tachycardic, RRR, S1S2 nml, no M/R/G
Abd – soft, NT, ND, NABS, no organomegaly
Neurological – AAOx3, CN II-XII intact
Labs
 WBC – 24.8
 Na – 130
 Hgb – 15
 K – 4.4
 Platelets – 198
 Cl – 88
 CO2 – 30
 PT – 14.6
 BUN – 19
 INR – 1.2
 Cr – 1.0
 PTT – 24.8
 Gluc – 106
 Ca – 9.6
• CRP – 18
• ESR – 19
• Urine
– Cocaine Pos
Any thoughts?
DDx
 Cellulitis
 DVT
 Superficial Thrombophelbitis
 Erysipelas
 Gas gangrene
 Necrotizing Fasciitis
A/P
 Cellulitis – bilateral?
 Pt started on IV clindamycin, IV vancomycin
 blood cx
 Get US bilat LE to r/o DVT
 X-ray LE, CT LE w/ contrast to r/o gas gangrene and/or
necrotizing fasciitis
 IVF
Hospital course
 Pt continued to spike temperature for next 2 days,
highest noted at 38.8
 US LE: -ve for DVT
 X-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?
Ddx
 Henoch Schonlein Purpura (HSP)
 Hypersensitivity vasculitis
 Wegener Granulomatosis
 Churg-Strauss Syndrome (Allergic Granulomatosis)
 Polyarteritis nodosa
 Buerger Disease (Thromboangiitis Obliterans)
 Infective endocarditis
 Thrombotic Thrombocytopenic Purpura
 Cocaine induced pseudovasculitis
 Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
Further work-up
 ANA screen – negative w/ <1:40
 CXR, ACE levels to r/o sarcoidosis – CXR unremarkable, ACE
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levels 59, CT chest – neg for hilar LADP or ILD
HIV Ab – negative
Hepatitis panel – non-reactive
C3 – 151
C4 – 37
RPR – non-reactive
TTE – negative for valvular lesions; normal EF; normal heart
function
CPK – high at 351 then trended down to 126
Hospital Course
 Pt was evaluated by dermatology service and Bx were
taken
 Pathology report verbal read - neutrophilic infiltration around
the small and medium size vessles showing leukocytoclastic
vasculitis
 ANCA work up – negative
 Blood cx – negative
 Pt fever controlled w/ tylenol, continued to have severe
10/10 pain in LE, legs were less tight and shiny
Hospital course
 Pt was started on solu-medrol 70mg IV per dermatology
recs
 Over 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 course
 Rheumatology consult placed and…
Rheumatology recs  Cryoglobulin
 Human leukocyte elastase
 Lactoferrin
 Cathespin
 Lupus anticoagulant
 Beta-2 microglobulin
 3-2 glycoprotein
Hospital course
 Pt continued to improve
 Pain subsided to 1-2/10 and pt switched to PO steroids
 Pt was discharged home and was to follow up as outpt in 2
weeks with rheumatology clinic
Ddx
 Cuatneous PAN (CPN)
 Hypersensitivity vasculitis
 Cocaine induced pseudovasculitis
Thank you