Question

A 50 year-old Hispanic female came into your 24-hr Emergency care clinic complaining of purpuric lesions on her left and right ankles. She stated that she was being treated for rheumatoid arthritis with leflunomide and steroids.

1.What is your initial differential diagnosis? Give at least three.

You begin to take a patient history and review of symptoms. She is originally from Venezuela but moved to the United States before Hugo Chavez and Nicolas Maduro came to power, and she has not returned in over nine years. She has lived in Corpus Christi for eight years with her husband and two children. She is not on blood thinners such as warfarin (Coumadin). She denies use of alcohol, tobacco, or illicit drugs. She lives in Flour Bluff but states she has not gone to the beach or been on the water for over five weeks. She has not eaten raw seafood in the last four weeks. She denies any known drug allergies.

2a. What conditions might you now exclude?

b. Why can you exclude these?

The patient had rhinorrhea and myalgia. She stated she had no sore throat, shortness of breath but a sporadic cough, felt no fever or chills, no nausea, vomiting or diarrhea, no abdominal pain, no leg swelling or pain in the extremities. Examination revealed temperature of 38.1°C, heart rate 106 beats per min, BP 126/68 mm Hg, respiratory rate 16 breaths per min, and oxygen saturation of 98%. Lungs were clear on auscultation. Her White blood cell count was 4600/microliter (normal 4500-11,000) lymphocyte count was 700/microliter (normal 1000-4800). Her electrolytes, kidney and liver function tests were within normal range.

3a. Do these findings allow exclusion of some of the differential diagnosis possibilities, and suggest some other possibilities?

3b. What other tests would you perform?

The patient was given nucleic acid amplification tests for COVID-19, influenza A, and respiratory syncytial virus—all were negative. She was sent home with fluticasone nasal spray, with the diagnosis of sinusitis. She returned two days later, complaining of shortness of breath. Her oxygen saturation had decreased to 94% .

4. What possibilities must now be considered? List at least four.

Radiography of the chest revealed a 5 cm mass in the left lower lobe. A CT scan revealed ground-glass opacity, and some left hilar lymphadenopathy.

5. What conditions from question 4 should be included?

Patient now had a temperature of 39oC, complained of a productive cough with green sputum, weakness, nausea and vomiting. The heart rate now increased to 115 beats per minute, BP was 138/85 mm Hg. Auscultation revealed crackles in the left lower lobe. Oxygen saturation dropped to 92% within the two hour wait in the emergency room.

6.a. What are the most likely conditions the patient could have?

b. What should your next steps be with this patient?

c. What is your diagnosis?

Answer 1

Initial differential diagnosis

· Petechiae: Flat lesions, macules ≤4 mm), typically initially bright red and then fade to a rust color .

· Ecchymosis: Flat lesions, macules and/or patches, >5 mm (, typically initially red or purple, but may fade to yellow, brown, or green).

· Palpable purpura: Elevated, round or oval, red or purple papules and/or plaques , sometimes barely palpable).

· Retiform purpura: Stellate or branching lesions, with angular or geometric borders. These are often palpable plaques, but can present as nonpalpable patches as well .

1. in a research study five patients reported had taken leflunomide for RA, 2-6 weeks prior to the onset of symptoms. They presented with fever, skin rash and internal organ involvement. Skin lesions started as exanthematous and purpuric rash, which progressed to erythroderma in three cases and TEN in one case.

2. Ground glass opacities in the lungs

It is typically diffuse, involving larger areas of one or multiple lobes. There are a variety of potential causes, including Pneumocystis pneumonia, late-stage adenocarcinoma, pulmonary edema, some types of idiopathic interstitial pneumonias, diffuse alveolar hemorrhage, sarcoidosis, and pulmonary alveolar proteinosis.