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Abdominal Pain and Petechial Rash in a 95-Year-Old Farmer

Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
1 Credit CME

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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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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Article Information

Corresponding Author: Mitsuyo Kinjo, MD, MPH, Okinawa Chubu Hospital, 281 Miyazato, Uruma City, Okinawa, 904-2293, Japan (kinjomitsuyo@gmail.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.

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

  • 1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
  • 1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
  • 1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
  • 1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
  • 1.00 credit toward the CME of the American Board of Surgery’s Continuous Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.

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