VCOM Carolinas Research Day 2023

Clinical Case-Based Reports

An Atypical Presentation of Exercise-Induced Vasculitis in a 34-Year-Old Male Samantha Diener OMS-III, Dr. Michaeleena Carr DO, Dr. Lindsay Tjiattas-Saleski DO, MBA, FACOEP Edward Via College of Osteopathic Medicine, Spartanburg, South Carolina

Abstract # CBR-17

Background

Image Findings

Differential Diagnosis

• EIV is commonly associated with golfers, hikers, and long-distance walkers over the age of 50, especially in hot climates. 1-4 This case may support that there is a broader range of underreported cases of EIV that do not fit this demographic. • Most cases resolve spontaneously within 10 days with supportive treatment, 1 but other treatments should be considered if the lesions are not improving with symptomatic treatment or there is necrosis or ulceration. 5 • Most literature does support that exercise-induced vasculitis is a diagnosis of exclusion and that other causes of systemic small-vessel vasculitis such as ANCA vasculitis, Henoch-Schölein purpura, and hepatitis should be considered. 5 • Hypotheses for the pathophysiology include: exercise-induced immune complexes cause complement activation and inflammation of vessels or disruption of the body’s vasculature response to exercise. • Increased body temperature causes vasodilation, while the SNS causes vasoconstriction in response to exercise. • Lipedema or venous insufficiency can disrupt these two systems, causing venous overfilling and extravasation of blood into the skin. 1,3-4,6 • Cases of EIV should continue to be reported, as many people are misdiagnosed and mistreated initially for a benign condition. Systemic Vasculitis 5 Cutaneous Vasculitis 5 —–ƒ‡‘—• ‹†‹‰• ‘†—Ž‡•ǡ —Ž…‡”•ǡ ’—”’—”ƒǡ ’‡–‡…Š‹ƒ‡ ”–‹…ƒ”‹ƒŽ ’ƒ’—Ž‡•ǡ ’—”’—”ƒǡ ’‡–‡…Š‹ƒ‡ǡ ’ƒ”–‹ƒŽ „Žƒ…Š‹‰ ‘ˆ Ž‡•‹‘• ›’–‘• ”—”‹–‹… ‘” „—”‹‰ •‡•ƒ–‹‘• ‘ˆ Ž‡•‹‘•Ǣ ƒ•›’–‘ƒ–‹ ›•–‡• ˜‘Ž˜‡† ‹ǡ ‹†‡›•ǡ ‡ƒ”–ǡ —‰•ǡ •›•–‡ǡ ‡”˜‘—• ›•–‡ ‹ ƒ–‹‰—‡ǡ ˆ‡˜‡”ǡ ™‡‹‰Š– Ž‘•• ƒ”–Š”ƒŽ‰‹ƒǡ ›ƒŽ‰‹ƒǡ ™‡ƒ‡••ǡ •Š‘”–‡•• ‘ˆ „”‡ƒ–Šǡ ƒ„†‘‹ƒŽ ’ƒ‹ǡ •‹—•‹–‹•ǡ …‘—‰Šǡ …Š‡•– ’ƒ‹ Discussion

• Subjective • A 34-year-old male presented to the emergency department for bilateral lower leg rashes that began 3 days prior. The rash had gotten progressively larger and darker. • He denied any significant past medical history or trauma. • He worked at a large store stocking, which required prolonged standing and walking throughout his workday. • Objective • Vitals: Temp. 98.2 ° F, HR 92 BPM, RR 18, SpO2 96%, BP 172/98 • Weight: 154 kg • Constitutional: Obese male • Skin: Warm and dry, capillary refill <2 seconds, bilateral lower extremities with nonpalpable, non-blanching, non-tender rash that cuts off at sock line without involvement of the feet • Assessment • Exercise-Induced Vasculitis • Plan • Supportive care: elevate the legs, compression stockings, NSAIDs and antihistamines as needed • Follow-up with PCP if symptoms have not resolved in 4 weeks for further workup and treatment. • Exercise-induced vasculitis (EIV) is a benign cutaneous small-vessel vasculitis that is underreported, often leading to an extensive workup at presentation. 1,2 • The skin lesions, also known as “golfer’s vasculitis” and “hiker’s rash”, often present in people who participate in activities that require prolonged walking and standing . 3,4 • Hot climates are a known trigger for EIV, and women are more commonly affected than men. 1,3 • EIV usually presents initially in people over the age of 50, and relapses commonly occur. 1-4 • The rash brought on by EIV is often pruritic or is accompanied by a burning sensation, although it can be asymptomatic. The sock area is often spared. It also usually resolves spontaneously within 10 days. 1-4 • Current literature supports performing extensive workup to rule out systemic causes of vasculitis at presentation. 5 Case

Figure 1 . Non-blanching erythematous lesion on the anterior right lower leg.

Figure 2 . Non-blanching erythematous lesion on the anterior left lower leg.

Interventions

Treatment Algorithm for Cutaneous Small Vessel Vasculitis 5

Supportive Care

Rest, Leg Elevation, Compression Stockings, NSAIDs for pain, antihistamines for pruritus.

Oral Prednisone

40-60 mg PO daily for 4-6 weeks.

References

Colchicine

0.6 mg BID or TID. Response usually seen within 1-2 weeks.

1. Espitia O, Didier Q, Le Bouch Y, et al. Exercise-induced vasculitis: a review with illustrated cases. American journal of clinical dermatology . 2016;17(6):635-642. doi:10.1007/s40257-016 0218-0 2. Cushman D, Rydberg L. A general rehabilitation inpatient with exercise-induced vasculitis. Pm & r : the journal of injury, function, and rehabilitation . 2013;5(10):900-902. doi:10.1016/j.pmrj.2013.04.015 3. Ramelet A-A. Exercise-induced vasculitis. Journal of the european academy of dermatology and venereology . 2006;20(4):423-427. doi:10.1111/j.1468-3083.2006.01504.x 4. Kelly RI, Opie J, Nixon R. Golfer's vasculitis. Australasian journal of dermatology . 2005;46(1):11-14. 5. Goeser MR, Laniosz V, Wetter DA. A practical approach to the diagnosis, evaluation, and management of cutaneous small-vessel vasculitis. Am J Clin Dermatol . 2014;15(4):299-306. doi:10.1007/s40257-014-0076-6 6. Prins M, Veraart JC, Vermeulen AH, Hulsmans RF, Neumann HA. Leucocytoclastic vasculitis induced by prolonged exercise. Br J Dermatol . 1996;134(5):915-918.

Dapsone

100-200 mg/day. Can also use in combination with colchicine.

Acknowledgements

Immunosuppressive Therapy

Mycophenolate mofetil, azathioprine, or methotrexate.

Thank you to the patient for allowing his case to be presented for educational purposes.

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