VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

01 A Rare Educational Case of Cutaneous Leukocytoclastic Vasculitis

Leukocytoclastic vasculitis (LCV) is a common form of small vessel vasculitis that involves inflammation of arterioles, capillaries, and postcapillary venules and is characterized on histopathological examination by neutrophilic inflammatory infiltrates, degeneration of neutrophilic nuclear contents (leukocytoclasis), fibrinoid necrosis, and damage to vessel walls. Cutaneous LCV (CLCV), also known as cutaneous small vessel vasculitis, describes LCV that is confined to the skin. CLCV affects males and females equally and can occur in patients of all ages. The hallmark clinical feature of CLCV is bilateral palpable purpura, especially on the lower extremities and buttocks. Most cases of idiopathic CLCV are self-limiting, but further workup needs to be performed if there are constitutional symptoms of fever, weight loss, night sweats, and malaise, which suggest systemic involvement. LCV is idiopathic in approximately half of all cases; infections and drugs are the most common triggers in the other half of cases. Streptococcus Shruthi Vijayalakshmi 1 , Shreyan A Patel 2 , and Admir Syla 1 Corresponding author: shruthi.vijayalakshmi@hcahealthcare.com 1 Internal Medicine, LewisGale Medical Center, Salem, VA 2 Edward Via College of Osteopathic Medicine-Virginia Campus

pyogenes is most commonly the culprit for post infectious LCV, but other infectious etiologies include Mycobacterium, Staphylococcus aureus, Chlamydia, Neisseria, and influenza. Chronic infections, such as hepatitis A/B and HIV, can also cause LCV. There are many drugs that have been associated with LCV including antibiotics, diuretics, allopurinol, NSAIDs, anticonvulsants, and amiodarone among others. Other less common causes of LCV include autoimmune disorders, malignancy, and, more recently, COVID-19 vaccines. Treatment for CLCV includes leg elevation, rest, compression stockings, and antihistamines for mild symptoms and a 4-6 week tapering dose of corticosteroids for moderate to severe symptoms. In rare cases, immunosuppressive agents may be needed. CLCV typically resolves over 3-4 weeks whereas the prognosis for systemic LCV is worse and depends on the severity of the organs involved. The most significant complications of LCV are skin ulcerations and subsequent secondary infections. Therefore,

prompt diagnosis and treatment are key to resolving symptoms and reducing morbidity from CLCV and systemic LCV. Here, we describe the case of a 23-year-old female who presented with palpable, erythematous papules on all her extremities and trunk. An extensive workup for infectious etiologies was performed. Serology testing was positive for HSV-2. A skin punch biopsy of her right lower extremity was performed, which confirmed LCV. However, immunoperoxidase staining of the biopsy sample for HSV was negative. She was started on oral prednisone for her idiopathic exanthem. She was discharged from the hospital two days later after improvement of her symptoms. She was tapered off prednisone over two weeks and did not have recurrence of CLCV.

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2 0 2 3 R e s e a r c h R e c o g n i t i o n D a y