Podiatry Arena members do not see these ads

Greetings all,

Ms X is a 13 year old girl, who is about 80 kg and 5 foot 8 inches (sorry about the mixed measurment units!) - large for her age, but within the expectations of her largish family.

Following a knee injury to the left leg (lateral dislocation of the patellar) 12 months prior, she developed a region of mottled erythema and hyposthesia on the lower anterior medial aspect of the affected leg. The vascular and neuro changes are limited to a 7 cm square area. (I'll append a photo later if I can, but there is nothing remarkable to see).

The region is not painful, just numb. On exercise the mottling diminishes and the area becomes more frankly erythematous, then resolves to usual status. There is slight and firm swelling over the area which does not change with exercise or rest.

These symptoms have not changed since their commencement 12 months ago. She is otherwise well, except for asthma for which she takes preventer medication and ventolin prn (generally once a day). Within the last 12 months she has had two courses of oral prednisolone related to the asthma.

It aint getting better, it aint getting worse. The knee is still dodgy, but responding to physio/orthoses. The strange mottling/numbness persists.

Your thoughts?

Felicity

Goodness me, this post has inspired a deluge of responses.

I forgot to mention that the affected area is noticeably colder to touch than the surrounding skin. (That should get the punters in Felicity).

Is everyone else as stumped as me?

Livedo reticularis

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

That's a good call Craig, but the damn area seems just a tad too isolated, and there is no exaccerbation by cold. I'll think more about that diagnosis though. No other signs of vasospastic disorders present.

Here's another thing to add to the pot. As I mentioned, the lass has pretty nasty asthma. We put her on the treadmill running for 5 mins (and she had a couple of puffs of Ventolin prior to exercise). Immediately post exercise we found:

Brachial BP 170/90
5 mins later 160/85
20 mins later 115/70

A Doppler of her Dorsalis pedis at these intervals demonstrated (bilaterally) monophasic, then biphasic then finally triphasic sounds.

Now, what I know about exercise physiology you could put on the back of a postage stamp and still have room to write the Lord's Prayer, but are these readings a tad abnormal for an otherwise healthy 13 year old girl? She plays sports regularly (netball) assisted by asthma medication, so she should have reasonable cardiovascular fitness levels.

Your thoughts?

Felicity

This seems like good resource on livedo reticularis:
http://www.dermnetnz.org/vascular/li...ascularis.html

Another stretch for consideration might be one of the vasculits's - maybe hypersentivity vasculitis:
http://www.emedicine.com/DERM/topic185.htm

__________________
Craig Payne
Department of Podiatry
La Trobe University
Melbourne, Australia
http://www.latrobe.edu.au/podiatry
__________________________________________________ ___________________________________
God put me on this earth to accomplish a certain number of things - right now I am so far behind, I will never die.
The views expressed above are those of the author and not that of La Trobe University
This is where I am, where are you?

I think you're on the right line there Craig. I willing to make the call Henoch-Schonlein purpura. Here's a weird thing, this girl's best friend had H-S Purpura a few years ago! What are the odds there?

Any thoughts on the hypertension?

Flip

Felicity:

Ventolin is a beta-agonist stimulator and, as such, may cause temporary increases in stimulation to the sympathetic nervous system, including a temporary elevation of systolic and diastolic blood pressure. I would imagine that the combination of the Ventolin inhaler and the exercise itself would explain the elevated blood pressure immediately post-exercise. By the way, an elevated blood pressure during exercise is not such a bad thing. http://www.pslgroup.com/dg/e196.htm

__________________
Sincerely,

Kevin

**************************************************
Kevin A. Kirby, DPM
Adjunct Associate Professor
Department of Applied Biomechanics
California School of Podiatric Medicine at Samuel Merritt College

e-mail: kevinakirby@comcast.net

Private Practice:
107 Scripps Drive, Suite 200
Sacramento, CA 95825 USA
My location

Voice: (916) 925-8111 Fax: (916) 925-8136
**************************************************

Ta Kevin. My god-daughter lives to see another day. Phew!

Hi Felicity,
With Haenoch-Schonlein purpura would one not also expect abdo pain/more non-specific (as opposed to traumatic) joint pain/and or renal symptoms. Also as this is a post viral reaction, does the young lady have a recent history of viral illness?

Just a few thoughts.

__________________
If you are on the rollercoaster, open your eyes and enjoy the ride.