A 65-year-old woman quick in emerge...

A 65-year-old woman quick in emergenciesed for evaluation of a rash in succession her bilateral lower extremities that she noticed several days earlier while gardening. She denied pruritus or pain. She had no other symptoms and was otherwise well. Her medical history consisted of hypertension, depression, and a right facial strengthen palsy secondary to Bell's palsy. She had no novel additions to or changes in her medications. Physical examination showed extensive petechiae and occasional patches of brownish pigmentation confined to her lower extremities. The lesions were macular and nonpalpable (Figures 1 and 2) The remainder of her physical examination was within normal limits. Laboratory evaluation included a out and out blood cell count, erythrocyte sedimentation rate (ESR) and a prothrombin and partial prothrombin time, all of which were all normal. A modern complete metabolic panel and urinalysis also were normal.

[FIGURES 1-2 OMITTED]

Question

Based upon the patient's history and physical examination, which individual of the following is the correct diagnosis?

[ ] A. Schamberg's disease.

[ ] B Henoch-Schonlein purpura.

[ ] C Hypersensitivity (leukocytoclastic) vasculitis.

[ ] D Idiopathic thrombocytopenic purpura.

[ ] E Contact dermatitis.

Discussion

The answer is A: Schamberg's disease. This is an unwonted eruption characterized by progressive, asymptomatic petechiae and patches of brownish pigmentation that may come into view in any age range from children to somewhat old persons. The lesions may present itself in any location but principally often affect the lower extremities. Characteristic "cayenne pepper" specks appear within and at the brims of old lesions, caused at erythrocytes breaking down outside the capillary and leaving hemosiderin deposits. The skin lesions are nonpalpable macules that may persist for month to years and are typically asymptomatic with the exception of for the cosmetic appearance. Males mind to be affected more than females.

The exact etiology is unknown, still a cellular immune reaction may play a part Occasionally, Schamberg's disease occurs secondary to a physic reaction, and withdrawal of the medication may improve the lesions. (1) Histologic examination exhibit tos a lymphocytic vasculitis involving the line vessels of the upper dermis (i.e., mainly the capillaries), with endothelial swelling and extravasated r life-current cells. (2)

Treatment of these asymptomatic lesions usually is not necessary, if it be not that some patients may wish to cloak the affected areas with topical cosmetics. If mild itching come into views topical steroids may be useful. Graduated compression elastic trousers may help on the lower extremities, because this condition is consideration to be caused by capillary leakage. Laser ablation of lesions has been attempted still has not proved successful.

Henoch-Schonlein purpura is an IgA-mediated hyper-sensitivity vasculitis that principally commonly affects young children still may occur in adulthood. The constellation of symptoms occurring greatest in quantity often with this condition includes a palpable purpuric rash forward the lower extremities or buttocks, arthritis, abdominal pain, gastrointestinal bleeding, and renal involvement. This patient was somewhat old and had no such associated symptoms, making this diagnosis unlikely.

Hypersensitivity vasculitis is a small sailing craft inflammatory disease mediated by deposition of immune complexe that cause palpable purpuric skin lesions. Prodromal symptoms usually include excitement malaise, myalgia, and joint pains. This original of vasculitis most commonly is caused by way of a drug reaction, but it also is associated with a number of infectious etiologies, like as hepatitis B and C human immunodeficiency virus, and endocarditis. The ESR almost always is elevated during active vasculitis. (3) Again, this patient had no as it was associated symptoms, her purpuric lesions were nonpalpable, and her ESR was normal.

Idiopathic thrombocytopenic purpura is a bleeding disorder characterized by way of low platelet numbers resulting from platelet destruction by the agency of the immune system. Skin hemorrhage, easy bruising, abnormal menstrual bleeding, or rapid and severe loss of family from the gastrointestinal tract may be found The diagnosis is apparent by means of a low platelet count and otherwise normal finished blood count. This patient had a normal platelet count

Contact dermatitis is an inflammatory skin condition. It is unlikely in this patient because there were no signs of skin inflammation upon examination and also no subjective symptoms in the same state [i]or[/i] condition as pruritus or burning.

The opinions and assertions contained herein are the private views of the author and are not to be constru as official or as reflecting the views of the U Army Medical Department or the U Army Service at large.

REFERENCES

(1) Abeck D Gros GE Kuwert C Steinkraus V Mensing H Ring J Acetaminophen-induced progressive pigmentary purpura (Schamberg's disease). J Am Acad Dermatol 1992;27:123-4

(2) Aiba s Tagami H. Immunohistologic studies in Schamberg's disease. Evidence for cellular immune reaction in lesional skin. Arch Dermatol 1988;124:1058-62