A 95-year-old woman presented to the emergency department with 24 hours of abdominal pain, 2 weeks of diarrhea, and 3 months of intermittent abdominal bloating and anorexia. She was a farmer in rural Japan who did not drink alcohol and had been diagnosed with bullous pemphigoid 8 months prior, initially treated with prednisolone (15 mg daily). Her medications at presentation were prednisolone (8 mg daily) and lansoprazole. She had experienced 1 episode of dyspnea on exertion 2 weeks before presentation but reported no fevers, cough, wheeze, nausea or vomiting, hematochezia, or melena. In the emergency department, her temperature was 37.7 °C (99.9 °F); blood pressure, 110/56 mm Hg; heart rate, 125/min; and oxygen saturation, 95% on room air. On physical examination her lungs were clear to auscultation, and her abdomen was diffusely tender to palpation without rebound. Skin examination revealed purpuric macules and small thumbprint-like patches on the upper abdomen and central chest (Figure 1).
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Corresponding Author: Mitsuyo Kinjo, MD, MPH, Okinawa Chubu Hospital, 281 Miyazato, Uruma City, Okinawa, 904-2293, Japan (email@example.com).
Published Online: April 14, 2023. doi:10.1001/jama.2023.4195
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patient’s son for granting permission to share the patient’s information. We also thank Rita McGill, MD, MS (Department of Nephrology, University of Chicago), for assistance with editing the manuscript. We also acknowledge Shuhei Yokoyama, MD, Shunichi Takakura, MD, and Soichi Shiiki, MD (Division of Infectious Diseases, Department of Medicine, Okinawa Chubu Hospital), for their care of this patient. None of these persons received compensation for their contributions.
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