ISSN:
1365-4632
Source:
Blackwell Publishing Journal Backfiles 1879-2005
Topics:
Medicine
Notes:
An 84-year-old Indian woman with no significant past medical history and no known drug allergies had been prescribed clarithromycin (250 mg twice daily) for pneumonia. The patient was receiving no other medications. Ten days after starting treatment, the patient developed a mild fever, eruption, and swelling of the ankles. Several days later, the patient developed a spreading, nonpainful, nonpruritic eruption, joint pain, gastrointestinal bleeding, and general malaise. Skin examination revealed numerous palpable purpuric macules and papules and petechiae on the lower extremities, mostly below the knees, and on the right hand. There were large blistering lesions around both ankles, some of which had ulcerated and had a necrotic center (〈link href="#f1"/〉). Blood streaked stool was noted during rectal examination. Laboratory tests showed a normal white blood cell count, hematocrit, and hemoglobin. Serum urea nitrogen was 22 mg/dL (8–18 mg/dL) and creatinine was normal. Urinalysis revealed proteinuria of 0.9 g/24 h (〈0.15 g/24 h) and a microscopic hematuria. Antistreptolysin O, antinuclear antibodies, cryoglobulins, and hepatitis serologies were all negative. Histology of the skin showed leukocytoclastic〈figure xml:id="f1"〉1〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD741:IJD_741_f1"/〉Extensive purpura on the distal legs. Overlying the medial malleolus of the left ankle is a large crusted erosion. An ischemic but intact blister roof is apparent at the peripheryvasculitis of superficial vessels with extravasation of red blood cells (〈link href="#f2"/〉). Direct immunofluorescence revealed immunoglobulin A (IgA) in superficial dermal vessels. Treatment with prednisone (1 mg/kg/day) was started and the arthralgias, hematochezia, and eruption resolved over the next 3 days. Renal function remained impaired, however, and the patient was discharged with a proteinuria of 0.56 g/24 h (〈0.15 g/day) on prednisone and omeprazole.〈figure xml:id="f2"〉2〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD741:IJD_741_f2"/〉Medium power picture showing fibrinoid necrosis of superficial vessels, neutrophilic infiltrate, and karyorrhectic debris (hematoxylin and eosin, ×100)
Type of Medium:
Electronic Resource
URL:
http://dx.doi.org/10.1046/j.1365-4362.1999.00741.x
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