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Hi all interested

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Interesting dermatology case which so far defied dx by several specialists.
Unresponsive to topical steroids or anitfungals. Onset approximately 4 years ago initially episodic in small isolated dorsal areas, accompanied by itchiness which patient reports only being relieved by his risky behavior of “lancing the blisters” with a needle. Has worsened progressively past six months and now is constant unresolved and more widespread problem.

My initial DD included shower embolism because of history of cardiovasc disease and sudden and episodic nature. However condition is now NOT episodic.

My other thought is possibility of warfarin induced vasculitis

Details below – ideas appreciated.

Patient 76y Male
PMHx: ischaemic heart disease type 1 diabetes mellitus diagnosis 1988. bladder cancer Dx /Tx July 2004.
PSHx: Cardiac angioplasty revascularisation
Medications: insulin,accupril, metformin, crestor novasen, amytriptylene as needed, gtn as needed, warfarin, emocort lotion for lower limb skin lesions
DM control: Insulin.
Vascular Status of Foot: Evidence of peripheral vascular disease noted, both feet pedal pulses absent, hairs absent on dorsum of digits, skin colour and temperature normal.
Neurological Exam: Semmes Weinstein Monofilament (10 gm threshold) detected throughout plantar surfaces of both feet, no evidence of loss of protective sensation.
History of foot complications: History of foot ulceration, superficial non-infected ulcer not involving tendon, joint capsule or bone (UTDWCS grade IA ulcer site) right foot 1st metatarsal head - single episode Feb 1998, healed April 1998, no recurrence - managed with local wound care and offloading with CAD/CAM foot orthoses and rocker sole modification to SAS.
Foot wear: Patient wears SAS shoe with rocker modification constantly. Denies walking barefoot at home.
SMBG: Patient reports good glycaemic control – range 5.00 to 8.00 mmol/l past four weeks.
Foot Structure; both feet rigid plantarflexion 1st ray – limited joint mobility.

Thanks

Martin

The St. James Foot Clinic
1749 Portage Ave.
Winnipeg
Manitoba
R3J 0E6
www.winnipegfootclinic.com

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Have you thought of doing a skin biopsy, I know its risky but given the unresponsive nature of the condition is it not a case of damned if you do and damned if you dont.

Helen

It looks like your patient has a case of purpura but the itching is an interesting feature which adds another dimension. My first thought would be Schamberg's disease which affects older men as a distinct purpura or petechaie type rash on the lower extremities. Often described as a "Cayenne pepper" rash on a slightly pigmented background. The aetiology is unclear but is thought to be immunological in nature. The condition may last months or many years. There is no treatment.

With the itching in mind, Purpura of Doucas and Kapentanakis (or itching purpura) is a more likely diagnosis. Very similar to the above and in fact some would say the same! Hope this is helpful.

Ivan

Helen and Ivan

Thanks for both your comments, I agree that a biopsy would be very useful and that after reading up on your suggestion, that some form of progressive pigmented purpura most likely. This problem is in the hands of a dermatologist presently and I will discuss with him further and post if any definative Dx is found.

cheers

Martin