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A 30-year-old woman presented with widespread, erythematous, purpuric macules and papules on the abdomen and extremities. The eruption had been present for approximately 8 months and consisted of asymptomatic, self-resolving, and continuously appearing macules and papules. Her medical history was significant for chronic hepatitis B infection, for which tenofovir was initiated 4 months ago. Review of systems was positive only for occasional arthralgias in her knees and ankles. She was not taking any other medications.
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Cutaneous small-vessel vasculitis (CSVV)
B. Evaluate for systemic vasculitis
The keys to the correct diagnosis are the physical examination and biopsy results. CSVV has a variable clinical appearance including purpuric papules, purpuric macules, urticaria-like lesions, petechiae, and ulcers.1- 4 A distribution predominantly involving dependent areas in a nonretiform pattern is also clinically consistent with CSVV.1,2 In the case of suspected CSVV, it is important to establish the diagnosis and to assess for other end-organ involvement.
CSVV is a vasculitis involving postcapillary venules in the skin. The condition most commonly manifests as palpable purpura on the bilateral lower extremities. The incidence of CSVV is between 39.6 and 59.8 cases per million people annually.1 A skin biopsy is used to confirm the diagnosis, and histopathology shows leukocytoclastic vasculitis with extravasated erythrocytes, a neutrophilic infiltrate, fibrinoid necrosis, and broken-down neutrophils releasing nuclear debris (leukocytoclasis). A second biopsy should be obtained for direct immunofluorescence whenever possible, to evaluate for IgA-related CSVV. Importantly, for accurate direct immunofluorescence results, the newest lesion or a lesion that appeared within the past 24 to 48 hours should be sampled.
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Corresponding Author: Roger S. Ho, MD, MS, MPH, The Ronald O. Perelman Department of Dermatology, New York University School of Medicine, 240 E 28th St, 11th Floor, New York, NY 10016 (Roger.Ho@nyumc.org).
Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Additional Contributions: We thank the patient for providing permisison to share her information.
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