44 year old female patient admitted to an OSH for fever and rash. She had an abrupt onset of headache, fever, chills, nausea, vomiting and arthralgia. Monospot was positive. The rash developed several days later and was accompanied by tenderness of the underlying skin. It started on her buttocks and lower extremities then spread to her face and upper extremities (Figures 1-5). She had recently been treated with amoxicillin for tooth pain.
Past medical history:
Bipolar disorder, endometriosis, breast reduction, no pregnancy complications
No known autoimmune or connective tissue disease
Smokes half pack per day, 1-2 glasses wine per day
Risperidone, trazadone, morphine prn pain
Livedo reticularis and retiform purpuric patches on cheeks, ears, trunk and proximal extremities (Fig 1-6).
BUN/creatinine within normal limits
WBC 2.2, Hb 9.8, Hct 27.9, Plt 198, ESR 69, CRP 158, LFT wnl, PT/PTT wnl,
Hepatitis panel, HIV, VZV IgM, Histoplasma were all negative
Routine blood (x5), urine and sputum cultures were negative
AFB and fungal cultures were negative, skin biopsy cultures also negative
Lyme antibody, Ehrlichia PCR negative
VDRL negative, cryoglobulin negative
RF, ANA, dsDNA, ENA negative, C3 and C4 were within normal limits, beta-2 glycoprotein negative
Antithrombin III, protein C and S were within normal limits
EBV and CMV IgG were positive (IgM negative)
Anticardiolipin IgM positive (47), IgM and IgA negative
CT scan of abdomen and pelvis showed fatty liver but no evidence of lymphoma or other abnormalities.
Click here for the Diagnosis.