An 80-year-old Hawaiian man of Chinese ancestry arrives at the emergency department with diarrhea and dehydration. You are called to admit him for acute renal failure. On entering the patient’s room, you note that he has a diffuse maculopapular rash and is wheezing.
Twenty-one months earlier, the patient suffered his first episode of gout. Since that time, he has been asymptomatic. Two months ago, his primary care physician obtained a uric acid level and found it elevated at 10.6 mg/dL. She started the patient on allopurinol 300 mg PO daily.
Twenty days ago (approximately 6 weeks after initiation of allopurinol), the rash developed along with generalized pruritus. The patient’s primary care physician referred him to a dermatologist for skin biopsy, and he discontinued allopurinol 11 days ago.
Just in the past week, the patient began to experience a metallic taste in his mouth, as well as anorexia, malaise, chills, dysuria, and nonbloody diarrhea. He became nauseous and decreased his oral intake, which led to dehydration and progressive weakness.
Additional medical history
- The patient’s medical history is significant for renal insufficiency, type 2 diabetes mellitus, hypertension, hyperlipidemia, chronic obstructive pulmonary disease, chronic nasal allergies, benign prostatic hypertrophy, osteoarthritis, and gout.
- He is taking the following medications: fluticasone inhalant 110 mcg daily; fluticasone propionate one spray in both nostrils daily; montelukast 10 mg PO daily; irbesartan 300 mg PO daily; amlodipine 5 mg PO daily; glyburide 2.5 mg PO BID; triamterene/hydrochlorothiazide 37.5/25 mg PO QOD; albuterol 90 mcg 2 puffs q6h prn; terazosin 2 mg PO qhs; simvastatin 40 mg PO daily; azelastine 137 mcg 1 spray in both nostrils prn; meclizine 25 mg PO daily prn; fexofenadine 150 mg PO qPM; cyclobenzaprine 10 mg PO qhs prn; and hydrocodone/acetamino- phen 5/500 mg 2 tabs PO daily prn.
Social history
- The patient recently arrived from Hawaii to visit his wife’s family.
- He does not drink alcohol, but he smokes 4 cigarettes a day.
Review of systems
- A review of systems is negative for the following: fever, sick contacts, history of renal calculi, hemoptysis, ocular or ENT symptoms, history of hepatic disease, peripheral neuropathy, and neurologic symptoms.
Physical examination
- The patient is alert and cooperative.
- Temperature is 97.9oF, blood pressure 110/52 mm Hg, pulse 112 beats per minute, respiratory rate 16 breaths per minute, oxygen saturation 96% on room air.
- Mucous membranes are dry.
- Auscultation of the heart is normal.
- Significant wheezing is present in bilateral lung fields, but requiring no use of accessory muscles during respiration.
- Abdominal exam is remarkable only for obesity.
- Trace pitting edema is present in both lower extremities.
- The maculopapular rash is diffuse and nonblanching. Scaling on the trunk, areas of erythema below the umbilicus, and coalescing macular lesions on bilateral lower extremities are present.
- Joints are not swollen or tender, and there are no tophi.
- There are no focal neurologic deficits, and deep tendon reflexes are normal.
Laboratory studies completed in the ED
- Blood urea nitrogen, 112 mg/dL ; creatinine, 3 mg/dL ; glomerular filtration rate (GFR), 22 mL/min (baseline ratio of blood urea nitrogen/creatinine, 36:1.57; baseline GFR, 43 mL/min)
- White blood cell count, 15 k/uL
- Hemoglobin, 14.3 g/dL ; hematocrit, 43.6%; platelet count, 307/uL
- Alanine aminotransferase and aspartate aminotransferase, 177 and 139 IU/L, respectively
- Direct, indirect, and total bilirubin, 0.60, 1.19, and 1.79 mg/dL, respectively
- Serum eosinophils, 22% (normal <6%)
- Erythrocyte sedimentation rate, 50 mm/h.
Radiology
- Chest radiographs (posterior-anterior, lateral) show a bilateral process consistent with atelectasis or lung scarring.
- Noncontrast computed tomography (CT) of the thorax confirms parenchymal scarring but no acute process.
- Hepatic sonography reveals increased echogenicity of the liver parenchyma consistent with an acute hepatocellular process.
- Magnetic resonance imaging (MRI) of the abdomen shows a diffuse process in the liver with trace parahepatic ascites.
- Renal ultrasound shows bilateral renal cysts with no hydronephrosis or urolithiasis.
- Cardiac echocardiography reveals left ventricular hypertrophy but normal ejection fraction.
- Noncontrast CT (head) and MRI (brain) show an acute right frontoparietal cerebrovascular accident and an old lacunar infarct.
Dermatologist’s report
- A skin biopsy reveals lymphocytic perivascular infiltrate with scattered eosinophils and mild spongiosis consistent with vasculitis.
Follow-up laboratory data
- Acute hepatitis panel is negative
- Uric acid, 13.8 mg/dL
- Urine eosinophils, 31% (normal <1%)
- Anti-neutrophil cytoplasmic antibody IgG, 1:40 mildly elevated (normal<1:20)
- Anti-nuclear antibody (ANA) IgG, none
- Glycosylated hemoglobin, 7.1%
- High-sensitivity C-reactive protein, 207.96 mg/L (>10 mg/L is very high)
In summary, this patient’s erythematous rash is a biopsy-confirmed vasculitis. Additional findings are hepatitis, acute on chronic renal failure, eosinophilia, and leukocytosis.