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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