November 2005

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History: A 25-year old African-American female, with a past medical history significant for systemic lupus erythematosus (SLE) complicated by class IV membranoproliferative glomerular nephritis, on chronic prednisone therapy, presented to the hospital September
24, 2005 with the chief complaint of bilateral "burning feet," along with an exquisitely painful, retiform, purpurpic eruption on bilateral feet, calves, knees, thighs, and the left elbow. She stated she had been taking a shower the morning prior to admission, looked down and saw what appeared to be a bruise on the left knee and "purple toes." Over the next 24 hours, the eruption spread to involve the aforementioned locations. She stated the pain was so severe that she was unable to rest her legs on the bed. Furthermore, any subtle palpation of the lesions caused her to scream out in pain. She denied a history of any similar rash. In fact, the only history of a rash she had in the past was a malar rash. She did complain of significant arthralgias present in her fingers and ankles. She denied fevers, chills, headaches, mental status changes, shortness of breath, diarrhea, or other constitutional symptoms.

One month prior to presentation, she was hospitalized with a left lateral calf cellulitis and abscess, which was incised, drained, and debrided on August 9, 2005. MRI was negative at that time for osteomyelitis. The final cultures grew oxacillin-sensitive Staphylococcus Aureus, Escherichia coli, Stentotrophomonas, and Bacteroides fragilis. At the time of admission, she was taking Bactrim-DS along with Flagyl.

Past Medical History: 1) SLE: diagnosed at during childhood. Anti-ds-DNA positive (9/11/05) in a high titer at 1:3083. ANA, Anti-Sm, anti-ribonuclear protein, and SS-A were positive. The lupus was complicated by pleural effusions, anemia, and renal disease.
2) Membranoproliferative glomerular nephritis (Class IV): Secondary to the lupus. Confirmed by renal biopsy March 2005. Baseline creatinine was 1.1 mg/dl on 9/16/05.

Physical Exam:Vital signs in the ER demonstrated a temperature of 39.9 C, a heart rate ranging from 130-150, and a blood pressure of 155/95. She was a thin woman, in significant pain, crying and moaning. Skin examination demonstrated a non-blanchable, non-palpable, well-demarcated, retiform purpura without overlying ulceration present on bilateral feet (Figs 1-2), lateral thighs, shins, the left knee (Fig3), the left elbow (Fig4), and faintly on bilateral dorsal hands. This rash was extremely painful to any touch. There was also a 5 x 10 cm ulceration, without erythema, foul smell, or drainage, located on the left lateral calf, at the previous surgical debridement site. There was no ocular or oral involvement.

Admission Laboratory
Creatinine: 3.6 (0.6-1.4); BUN: 63 (8-25); Plasma protein: 5.2 (6.5-8.5); Albumin: 2.3 (3.6-5.0); Bili: 0.3 (0.3-1.1); Alk Phos: 90 (38-126); AST: 66 (11-47); ALT: 60 (7-53)

Urinalysis:
Protein: +3; Glucose: negative; Ketones: trace; Bili: +1; Blood: +3; Nitrites: negative; Leukocyte esterase: +2 RBC: 50 (0-3 HPF); WBC: 30 (0-5HPF); Bacteria: trace; Coarse granular casts: 2 or more (none)

CBC: WBC: 10.7 (3.8-9.8); Hgb: 8.6 (12.1-15.1); Hct: 24.9 (36.1-44.3); Plt: 93K (140-440K);
Haptoglobin: 282 (27-220)

PT: 17.1 (11-15.5): INR: 1.33 (0.8-1.2): PTT: 47.6 (23-35): D-dimer: >20 (0.22-0.5)
Fibrinogen: 407 (150-400)

ESR: 61 (0-20): CRP: 306 (<10): Anti-ds-DNA: 1:4052: Lupus anticoagulant: 1.3 (0-1)
Anticardiolipin antibodies: 18.2 (0-9)Blood cultures: negative: Urine cultures: negative

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