54 yo man with necrotizing vasculitis

Abstract: A 54 year old man presents with long-standing rosacea and a few week history of mildly pruritic papules on his thighs.

HPI: The patient is otherwise well and has been treated with doxycycline for greater than five years for severe rosacea. Recently, it has not been effective. He presented for alternative therapy; and at the time of the visit he mentioned an a pruritic papular eruption of his thighs for two to three weeks. He has had recent onset hypertension and was started on HCTZ about a month ago.

O/E: Erythematous papules and small nodules on face. There are scattered three - four mm papules erythematous papules on the medial thighs. The remainder of the examination is unremarkable.

Clinical Photos:

Subtle Lesions on Thighs

Pathology: Necrotizing vasculitisof deep dermal artery. (Photomicrographs courtesy of Marjan Mirzabeiji, M.D., Boston University Department of Dermatology, Dermatopathology Section)

Lab: CBC normal, Chemistries normal, BUN/Cr normal, ANA 1:1280 Homogenous, ANCA panel negative

Diagnosis: Cutaneous Polyarteritis Nodosa (drug-induced) or microscopic polyangiitis. Doxycycline or HCTZ may be putative.

Discussion: This is an "interesting" case. A man walks in with rosacea and winds up with necrotizing vasculitis. He has some protein in his urine and a positive ANA. There's an old saying: It is often more important to treat the patient who has the disease than the disease the patient has. This may be a case in point.

Questions: What is your diagnosis and what more would you do?

Reference:
Rogalski C, Sticherling M. Panarteritis cutanea benigna--an entity limited to the skin or cutaneous presentation of a systemic necrotizing vasculitis? Report of seven cases and review of the literature. Int J Dermatol. 2007 Aug;46(8):817-21
Abstract: In 1931 Lindberg described a limited and benign subcutaneous form of panarteritis nodosa, which, in contrast to systemic panarteritis, only affects the skin. The terms panarteritis nodosa cutanea benigna, cutaneous polyarteritis nodosa, apoplexia cutanea Freund as well as livedo with nodules are used synonymously for this vasculitis which predominantly affects women in the fifth decade of life. Cutaneous lesions characteristically comprise painful subcutaneous nodules or vasculitis racemosa at the lower extremities. The cutaneous panarteritis may be regarded as its own entity or an isolated skin manifestation within systemic panarteritis nodosa. Full Abstract.

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Teledermatology Rules: Vasculitis

Abstract: 2o yo man with one week history of palpable purpura.
HPI: This 20 yo college student was started on isotretinoin for severe cystic acne a month before he developed a rash on his legs. He also had an upper respiratory infection two weeks before the eruption began. He is away at school (a two hour drive). His mother called the office and spoke to my secretary. Busy week. When I heard that he had a rash, I relayed the message that it was probably the common dermatitis we see with patients on isotretinoin and if worried to send me a photo. Two days later, this photo was sent:


The patient was then emailed and asked to come in the next day. Labs were ordered done before the visit.

O/E: Palpable purpura both L.E. Right ankle swollen and tender. Patient limping.

Lab: CBC normal, UA normal. Pending Labs: Throat culture, ANA, ASOT. (Hep C, Stool for OB, not ordered)

Path: Biopsy performed. Not back

Diagnosis: Leucocytoclastic vasculitis. Etiology: The URI, isotretinoin, idiopathic

Plan: Rest for a few days. No specific therapy at this time except stopping the isotretinoin. If he improves uneventfully without evidence of GI or renal involvement will offer a re-challenge with isotretinoin.

Discussion: A few cases of LCV have been reported with isotretinoin. This patient has severe cystic acne with scarring and it would be a shame to withhold drug if it were not putative for the LCV. I admit I did not pay proper attention to the first telephone call. This illustrates the power of teledermatology which can be almost standard in a few years as cell phone cameras become better and people know how to use them more adroitly.

Questions: What are your thoughts and suggestions?

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