Nirav Pavasia

1
Red Medicine MR

• Nirav Pavasia

2
Case

• C/C My legs are in severe pain
• HPI Pt is a 38 yo BM w/ PMH of HTN, cocaine
  abuser, presented to the ER w/ swelling and
  severe pain in both legs. Pt describes pain as
  sharp and burning, rates 10/10, tender to touch,
  non-radiating, associated w/ tightness,
  aggravated by movement and no relieving factors.
  Reports that the pain has been going on since 1
  week but suddenly got worse last night and woke
  him up from sleep. Pt has not been able to
  ambulate 2/2 excruciating pain. Pt denies any
  similar episodes in the past. Pt has noticed
  subjective fevers and sweats for the past 2-3
  days.
• Denies any trauma to the LE, recent travel, chest
  pain, SOB, n/v, dizziness, lightheadedness,
  abdominal pain, change in bowel or bladder
  habbits, wt loss or wt gain.

3

• ROS Otherwise ve unless stated per HPI
• PMH HTN
• PSH None
• FH HTN, DMII, CAD
• SH smokes 1.5 ppd, gt20 yrs drinks 12pk
  beer/day, gt20 yrs Snorts cocaine regularly
  last use day before admission

4
VS

• Temp 38.3
• Pulse 104
• BP 169/95
• RR 18
• O2 sat 97 RA
• Allergies NKDA
• Meds HCTZ

5
PE

• Gen WN, WD, in mild distress due to severe LE
  pain
• LE skin hot to touch, shiny, tightness and TTP
  in bilat LE, strength 3-4/5 due to pain, 4x5
  palpable erythematic plaque like lesion in R
  calf, 2 peripheral pulses bilat ext, no crepitus
  noted
• HEENT NC/AT, EOMI, PERRLA, dry oral mucosa, no
  LADP, no JVD
• Chest CTABL, no R/R/W
• CV tachycardic, RRR, S1S2 nml, no M/R/G
• Abd soft, NT, ND, NABS, no organomegaly
• Neurological AAOx3, CN II-XII intact

6
Labs

• WBC 24.8
• Hgb 15
• Platelets 198
• PT 14.6
• INR 1.2
• PTT 24.8

• Na 130
• K 4.4
• Cl 88
• CO2 30
• BUN 19
• Cr 1.0
• Gluc 106
• Ca 9.6

• CRP 18
• ESR 19
• Urine
• Cocaine Pos

7
Any thoughts?
8
DDx

• Cellulitis
• DVT
• Superficial Thrombophelbitis
• Erysipelas
• Gas gangrene
• Necrotizing Fasciitis

9
A/P

• Cellulitis bilateral?
• Pt started on IV clindamycin, IV vancomycin
• blood cx
• Get US bilat LE to r/o DVT
• X-ray LE, CT LE w/ contrast to r/o gas gangrene
  and/or necrotizing fasciitis
• IVF

10
Hospital course

• Pt continued to spike temperature for next 2
  days, highest noted at 38.8
• US LE -ve for DVT
• X-ray, CT LE wnl, no evidence of soft tissue
  edema, abscess, or gas noted. Normal limit LE
  w/o any pathology. No lymphedematous changes or
  any inflammatory changes were identified in
  either of the LE.
• The erythamatous plaque like lesion in the R calf
  now beginning to spread in centrifuge fashion
  towards proximally and appeared in LLE as well
  around the ankle and toes.

11
(No Transcript)
12
(No Transcript)
13
(No Transcript)
14
(No Transcript)
15
Any thoughts?
16
Ddx

• Henoch Schonlein Purpura (HSP)
• Hypersensitivity vasculitis
• Wegener Granulomatosis
• Churg-Strauss Syndrome (Allergic Granulomatosis)
• Polyarteritis nodosa
• Buerger Disease (Thromboangiitis Obliterans)
• Infective endocarditis
• Thrombotic Thrombocytopenic Purpura
• Cocaine induced pseudovasculitis
• Stevens-Johnson Syndrome and Toxic Epidermal
  Necrolysis

17
Further work-up

• ANA screen negative w/ lt140
• CXR, ACE levels to r/o sarcoidosis CXR
  unremarkable, ACE levels 59, CT chest neg for
  hilar LADP or ILD
• HIV Ab negative
• Hepatitis panel non-reactive
• C3 151
• C4 37
• RPR non-reactive
• TTE negative for valvular lesions normal EF
  normal heart function
• CPK high at 351 then trended down to 126

18
Hospital Course

• Pt was evaluated by dermatology service and Bx
  were taken
• Pathology report verbal read - neutrophilic
  infiltration around the small and medium size
  vessles showing leukocytoclastic vasculitis
• ANCA work up negative
• Blood cx negative
• Pt fever controlled w/ tylenol, continued to have
  severe 10/10 pain in LE, legs were less tight and
  shiny

19
Hospital course

• Pt was started on solu-medrol 70mg IV per
  dermatology recs
• Over the course of 2-3 days pts pain much
  improved, rated 3-4/10 and erythamatous lesions
  began to fade away
• Vancomycin and Clindamycin stopped as WBC count
  normalized and pt afebrile for gt3 days as well as
  clinical suspicion less likely for infectious
  etiology
• PT/OT consult placed pt began to ambulate slowly

20
Hospital course

• Rheumatology consult placed and

21
Rheumatology recs -

• Cryoglobulin
• Human leukocyte elastase
• Lactoferrin
• Cathespin
• Lupus anticoagulant
• Beta-2 microglobulin
• 3-2 glycoprotein

22
Hospital course

• Pt continued to improve
• Pain subsided to 1-2/10 and pt switched to PO
  steroids
• Pt was discharged home and was to follow up as
  outpt in 2 weeks with rheumatology clinic

23
Ddx

• Cuatneous PAN (CPN)
• Hypersensitivity vasculitis
• Cocaine induced pseudovasculitis

24
Thank you