February 2008

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History: 31 y/o white male with a history of recurrent sinusitis was admitted to Barnes-Jewish Hospital with a 4 week history of migratory arthritis, fevers, increasing dyspnea, hemoptysis, and an asymptomatic lower extremity rash.

Past Medical History: Hypertension, recurrent sinusitis, gout, morbid obesity
Medications: Tylenol, Ibuprofen- PRN

Social History: Smoked 1ppd x 17 years
Family History: Noncontributory
Vitals: T 38.3, HR 134, BP 127/107, RR 22, O2 sat 96-98% on 100% Non-rebreather.

Physical Exam: Significant findings included single hemorrhagic pustule on the right lower abdomen (Fig.1). There were also purpuric papules on the bilateral anterior distal legs, plantar feet, and distal toes (Figs.2 & 3- Note lesions outlined by medical team). Full assessment of the nasal and oral mucosa could not be performed because the patient was intubated. Petechiae on the tip of the tongue were noted on the admission H&P.

Labs: WBC: 8.6, Hgb/Hct: 9.4/26.3, Platelets: 222, BUN: 71, Creatinine: 6.8, U/A: 2+ protein, 3+ blood, ANA: negative, Hepatitis B surface antigen: negative, Hepatitis C antibody: negative, Serum cryoglobulins: negative, HIV: negative, cANCA: positive (1:1280), tissue culture: negative, initial blood cultures: negative, CXR: bilateral opacities

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