A 30 year-old male was transferred from an outside hospital with palpable purpura (Figures 1,2,3) and acute renal failure with a creatinine of 14.8. The patient reported a 6 week history of a rash on his lower legs that was treated successfully with an unknown oral medication, likely an antibiotic or cortocosteroid. However, the rash reappeared in 1 week. The patient also complained of diffuse joint pain and general malaise. During hospitalization the patient was found to have a 3/6 holosystolic murmur and outside hospital records reported blood cultures positive for Streptococcus viridans. A transthoracic echo showed a bicuspid aortic valve with severe aortic regurgitation and stenosis, and moderate mitral regurgitation.
PHYSICAL EXAM: Afebrile, vitals within normal limits. Poor dentition.
Palpable purpuric papules and plaques on the arms, dorsal hands, abdomen, legs and dorsal feet. Moderate swelling of the hands, knees and feet
LABORATORY VALUES : Cr 14.8, BUN 17, UA: 3+ blood, 2+ protein; >50 RBCs on urine microscopy.
WBC 3.2; Hgb 8.6; Hct 24.9; Plts 178. ESR 72, CRP 189
C3 3.8; C4 31.8 (both low), ANA negative, ANCA positive, 1:40, RF 50
Cryoglobulins positive, 166, HIV negative, Hepatitis A, B, and C negative
Pt was unable to tolerate a TEE.
Jaw films: multiple dental caries and lucent areas that were concerning for peri-apical abscesses.
Click here for the diagnosis