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Notes: A 22-year-old white woman with a past medical history significant for left-sided ulcerative colitis since June 1996 was in good control until July 1998 when she developed bloody diarrhea treated with oral steroids. In September 1998, she was admitted to Mount Sinai Hospital because of worsening symptoms. Colonoscopic biopsy revealed recurrent ulcerative colitis. During the admission, she developed a painful erythematous plaque with central healing of 3 weeks' duration on the left side of the chest. A 3-mm punch biopsy was performed from the edge of the plaque. The patient underwent subtotal colectomy and ileostomy because of failure to respond to the medical treatment. Although no change of the skin lesion was observed after the biopsy, the lesion started to become less painful and flat, followed by complete resolution several days to a week after subtotal colectomy.The skin biopsy showed a mild epidermal hyperplasia, papillary dermal edema, and a superficial and deep dermal non-necrotizing granulomatous inflammation with numerous neutrophils ( 〈link href="#f1"〉Fig. 1). The granulomata were seen in perivascular and interstitial areas, with occasional foci at the dermal subcutaneous junction ( 〈link href="#f2"〉Fig. 2). The granulomatous infiltrates stained positively with KP-1 (CD68), confirming the histiocytic nature of the lesion ( 〈link href="#f3"〉Fig. 3). As there was a neutrophilic infiltrate associated with the granulomata, an infectious etiology was suspected; however, special stains for acid-fast bacillus, fungus or bacteria failed to reveal microorganisms. The colonic resection showed universal mucosal colonic involvement without granulomata consistent with fulminant active ulcerative colitis.〈figure xml:id="f1"〉1〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD886:IJD_687d_f1"/〉Low magnification view of the lesion showing superficial and deep perivascular and interstitial non-necrotizing granulomata with neutrophilic infiltrate〈figure xml:id="f2"〉2〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD886:IJD_687d_f2"/〉High magnification view of the lesion showing non-necrotizing granulomata at the dermal subcutaneous junction〈figure xml:id="f3"〉3〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD886:IJD_687d_f3"/〉Intermediate magnification view of the granulomata showing positive reaction with CD68 antibody

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)