Left Lower Extremity Pain, Swelling and Purpuric Rash in a 37 Year Old Male

Emily Mecklenburg, MD*, Maine Medical Center, Portland, ME

Meeting: Hospital Medicine 2016, March 6-9, San Diego, Calif.

Abstract number: 677

Categories: Adult, Clinical Vignettes Abstracts

Case Presentation:

BM is a 37 y.o. male with a past medical history significant for irritable bowel

syndrome. He presented to Maine Medical Center from a rheumatology office

with the chief complaint of left lower extremity swelling. Patient reported the

swelling developed 3 weeks after being struck by his dog in the leg and few

weeks after a plane ride to and from Chicago. He presented himself to his PCP

for initial evaluation. His PCP noted left lower extremity swelling and

discoloration. She also noted petechiae on both lower extremities bilaterally. She

was concerned for  possible vasculitis with secondary cellulites of the left lower

extremity. She started the patient of keflex and prednisone then referred patient

to Rheumatology for further evaluation and management. Patient was follow

rheumatology who felt patient should be admitted for further evaluation for

possible focal myositis. Patient had an initial 3 day hospital course.  He was

noted on presentation to have mildly leukopenia, and anemia. He was imperially

started on vancomycin and prednisone was discontinued. US was negative for

DVT. MRI was nonspecific but showed hyperintensity of the gastrocnemius

muscle. A muscle biopsy was preformed and results were pending at time of

discharge from first hospitalization. Patient was discharge on doxycyline with

follow up with Rheumatology. Patient returned to Maine Medical Center for non

improvement of left lower extremity 3 days after initial discharge. Patient was

started imperially on Vancomycin for concern for worsening cellulitis. Patient was

noted to be anemic, leukopenic, platelets were within normal limits. C

protein and ESR were mildly elevated. Rheumatology and Infectious disease

were consulted to aid in diagnosis and treatment.

Discussion:

Differential included focal myositis with superimposed cellulitis , infected

hematoma, vasculitis or lupus. Vasculitis panels and ANA were found to be

negative. Preliminary read on the pathology tissue showed non

inflammation with no indication of myositis. Cultures of blood and muscle biopsy

showed no growth. Orthopedics was consulted for suspicion of infected

hematoma of left leg. Repeat MRI showed slight worsening of inflammation with

finding consistent with post traumatic changes of large fascial hematoma vs

infected hematoma. Orthopedics did not feel there was role for surgical

intervention. Patient remained afebrile and showed little improvement or

worsening of symptoms on IV antibiotic. A review of social history showed that

the patient had an extremely strict diet of eggs and spinach secondary to irritable

bowel syndrome. Vitamin level were taken at previous hospitalization showed a

Vitamin C level 0.0. Patient was start on vitamin C supplements and showed

remarkable improvement of symptoms.

Conclusions:

Patient was diagnosed with Scurvy at second hospitalization. Testing for

Whipple patient vitamin C deficiency was due to restricted diet.

To cite this abstract:

Mecklenburg E. Left Lower Extremity Pain, Swelling and Purpuric Rash in a 37 Year Old Male. Abstract published at Hospital Medicine 2016, March 6-9, San Diego, Calif. Abstract 677. Journal of Hospital Medicine. 2016; 11 (suppl 1). https://www.shmabstracts.com/abstract/left-lower-extremity-pain-swelling-and-purpuric-rash-in-a-37-year-old-male/. Accessed September 18, 2019.

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