Purpuric Lesions on Acral Sites

Abstract

A woman in her 80s with a history of nonischemic cardiomyopathy and chronic kidney disease presented with purpuric lesions on her face, elbows, knees, and feet. She was initially admitted for altered mental status in the setting of an unwitnessed fall and was noted to have "bruises" on her lower extremities. Dermatology was consulted after the development of new lesions on her nose, ear, and the extensor surfaces of her arms bilaterally. Admission laboratory test results showed hypercalcemia (calcium level, 11.5 mg/dL) and acute kidney injury (creatinine level, 5.6 mg/dL).On physical examination, the patient's nose, bilateral cheeks, forehead, and left ear (helical rim and antihelix [ Figure, A]) were found to have dusky purpuric macules and patches. Her knees, feet, and the extensor surfaces of her arms had reticulated purpuric macules and patches. There was skin sloughing off the lesions on her elbows (Figure, B) and knees. Fourmillimeter punch biopsy specimens were taken from the left ear, right arm, and forehead ( Figure, C and D).

Type I cryoglobulinemic vasulitis with eosinophilia

“…[2] Also, many other case reports showed Type I monoclonal cryoglobulinemia with IgG-Kappa, the same as our patient. [5,7,14–17]…”