June 2011



History: A 52 year-old white female presented to the Barnes-Jewish Hospital emergency department complaining of painful skin lesions at the bilateral cheeks, external ears, and breasts that developed over the course of four days (Figure 1). Soon after admission, the patient developed polyarticular, symmetric joint pain.

Past medical history: Recurrent MRSA abscesses, polysubstance abuse (cocaine, alcohol, marijuana), s/p saline breast implantation surgery

Medications: Acetaminophen PRN; received vancomycin and cefepime in the ER

Physical exam: Tender purpuric plaques of the bilateral cheeks, lobules of the external ear, and breasts

Labs: Hepatitis panel, RPR, HIV negative; UDS positive for cocaine; PT/PTT, protein C/S, coags normal; CBC, CMP on admission normal – ANC dropped from 3.0 to 0.7 within several days of admission; no blood or protein on UA; ANA, anticardiolipin antibody, Rf negative; Lupus anticoagulant positive; P-ANCA positive at 1:320, myeloperoxidase positive

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