A Patient Presenting with Palpable Purpura, Necrotising Lesions and Swelling in Bilateral Lower Extremities: Case Report

A Patient Presenting with Palpable Purpura, Necrotising Lesions and Swelling in Bilateral Lower Extremities: Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Patient Presenting with Palpable Purpura, Necrotising Lesions and Swelling in Bilateral Lower Extremities: Case Report Murat AY This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6776460/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective: In the subtype of leukocytoclastic vasculitis, various drugs, infections and malignancies play a role in the etiology and can also be seen in ANCA-associated vasculitis, systemic connective tissue diseases, cryoglobulinemic vasculitis and IgA-vasculitis. The decisive factor in the diagnostic approach is to first determine whether the process is limited to the skin or whether there is systemic involvement. Case: 49-year-old male, no known history of chronic disease and no history of regular medication use. The patient was admitted to Cardiovascular Surgery and Dermatology clinics 10 days before the clinical evaluation with complaints of bruising, itching and swelling in the legs. Physical examination revealed polyarthralgia, bilateral ankles, palpable purpura starting from the anterior aspect of bilateral lower extremities and extending to the femur and upper extremities and necrotizing lesions with crusts on bilateral ankles. Computed tomography scan revealed thrombus distal to the aorta distal to the left subclavian artery origin, splenic infarction and right renal infarction. Skin punch biopsy pathology report was histomorphologically compatible with vasculitis and renal biopsy report was compatible with IgA-nephropathy. Methylprednisolone 0.5 mg/kg/day and Cyclophosphamide+MESNA were started with the diagnosis of IgA-vasculitis and she was in remission at the end of treatment and is under follow-up and treatment with Mycophenalate mofetil. Discussion: IgA-vasculitis can also be seen in adulthood, although less frequently, and is not always preceded by the typical clinical tetrad of abdominal cramps, arthralgia, palpable purpura and renal involvement. Cases of IgA-vasculitis are rare, especially where thrombus formations are commonly observed. Palpable Purpura Vasculitis Thrombus Infarct Figures Figure 1 Figure 2 Figure 3 1. Introduction Purpura is a non-bleeding lesion of the skin, mucosal and serosal surfaces caused by infiltration of erythrocytes into the skin. Palpable purpura consists of red and/or purple papules or plaques that are raised from the skin, round or oval in shape, while retiform purpura is described as angular or geometric shaped lesions that can sometimes branch. Peripheral erythema may occur in lesions that develop secondary to inflammatory processes and areas of necrosis may be seen due to tissue infarction. Purpuras develop as a result of complete vascular occlusion and vascular damage in cutaneous vascular structures. Lesions may develop as a result of occlusion of cutaneous vascular structures by thrombus protein or emboli, or as a result of direct damage to the vasculature by vasculitic processes, calciphylaxis and severe opportunistic infections. Purpura size is generally expressed as 4–10 mm in the literature. Palpable purpuras are most commonly found symmetrically on the lower extremities. Acute unilateral lower extremity swelling can be seen especially in cases with chronic venous insufficiency or deep vein thrombosis, while acute bilateral lower extremity edema can be seen secondary to various diseases such as dihydropyridine group calcium channel blockers, acute heart failure, acute nephrotic syndrome, acute deep vein thrombosis especially secondary to malignancies and inflammation ( 1 ). It can also be seen in ANCA-associated vasculitis, systemic connective tissue diseases, cryoglobulinemic vasculitis and IgA-vasculitis, with various drugs, infections and malignancies playing a role in the etiology, especially in the subtype of leukocytoclastic vasculitis. The decisive factor in the diagnostic approach is to first determine whether the process is limited to the skin or whether there is systemic involvement. Histopathologic confirmation is usually required, especially after a detailed anamnesis and physical examination. A recent history of symptomatic drug use due to upper respiratory tract infection, the case was initially considered as limited involvement and referred to Internal Medicine and Rheumatology clinics for follow-up after the case showed signs of systemic involvement, Although typical systemic involvement findings were not observed, the observation of widespread thrombi and consequently widespread infarct areas in the imaging studies is thought to reveal the importance of approaching the case in a way to cover the spectrum from rare drug-related cases seen in the literature to systemic diseases in differential diagnoses and close follow-up of the case in processes that may require differential diagnosis and rapid treatment. 2. Case 49 years old male, no known history of chronic disease and regular medication use. The patient was admitted to the Cardiovascular Surgery clinic 10 days ago with complaints of bruising, itching and swelling in his legs. Subsequently, the patient was admitted to the Dermatology clinic with similar complaints. As a result of the evaluation of the patient and request for tests, it was learned that acute phase reactants were found to be high in the patient, infective pathologies were primarily evaluated in the patient, and coronavirus disease (COVID) polymerase chain reaction (PCR) was found to be negative. As a preliminary diagnosis, drug-associated vasculitis, hypersensitivity vasculitis, Cutaneous Polyarteritis Nodosa (PAN) and Henoch-Schönlein Purpura (HSP, IgA- vasculitis) were considered and after skin punch biopsy, Methylprednisolone was started at 0.5 mg/kg/day and the patient was referred to our Internal Medicine and Rheumatology clinic for diagnosis and follow-up. In the anamnesis, it was learned that the patient had a history of symptomatic treatment with pseudoephedrine, oxolamine, chlorpheniramine and paracetamol secondary to upper respiratory tract infection 15 days before the clinical presentation, but no other history of drug use. The patient's first C-reactive protein (CRP) value before steroid treatment was 146.3 mg/dL and the second CRP value after the initiation of steroid treatment was 58.1 mg/dL. His medical history revealed a smoking history of 30 pack/year and no history of rheumatologic disease or malignancy in his family history. Rheumatologic examination of the patient revealed no significant findings except morning stiffness and dyspnea. Rheumatologic physical examination findings revealed polyarthralgia, absence of intestinal angina, palpable purpura that did not fade with pressure starting from the anterior aspect of bilateral ankles and bilateral lower extremities and extending to the femur and upper extremities, and crusty necrotizing lesions on bilateral ankles. The findings of crusted necrotized lesions and palpable purpura in bilateral lower extremities found on physical examination of the patient are shown in Fig. 1 . The patient was interned to the clinic. In laboratory tests; CRP: 294.9 mg/dL, Sedimentation: mm/hour, creatinine: 1.1 mg/dL, Rheumatoid factor: 17.2 IU/mL, IgA: 466 mg/dL, D-dimer: 21.9 mg/L, leukocytes (WBC): 16.880 10 3 uL, no hypocomplementemia, Anti-ds DNA negative, ANA and ANA-blot panel negative, ANCA negative, Quantiferon negative, Antiphospholipid antibody syndrome (APS) antibodies negative, thrombophilia panel negative, proteinuria of 0.87 grams/day in 24-hour urine. Thoracic and abdominal tomography with contrast was ordered. Thorax tomography findings revealed a hypodense filling defect with the appearance of a floating thrombus measuring approximately 17x8 mm in the axial plane adjacent to the level of origin of the left subclavian artery distal to the arcus aorta. Abdominal tomography findings revealed a hypodense lesion measuring approximately 35x33 mm in the medial upper pole of the spleen, which was evaluated in favor of splenic infarction, and a hypodense area affecting the right kidney lower pole cortex and medulla, which was evaluated in favor of infarction. Abdominal angiography showed no additional findings and no occlusion was observed. Bilateral lower extremity doppler ultrasonography showed no evidence of deep vein thrombosis (DVT). Echocardiography, which was requested for possible infective endocarditis and myocarditis, revealed no vegetation and no additional findings. The appearance of a thrombus at the origin of the subclavian artery is shown in Fig. 2 and the findings of right renal infarction are shown in Fig. 3 below. The patient was evaluated on the 3rd day of post-internatization follow-up due to sudden abdominal cramps and abdominal pain. Hyperlactatemia was detected and the patient was evaluated by the General Surgery clinic for possible Mesenteric Ischemia and Mesenteric Ischemia was not considered in the patient. Tissue plasminogen activator (t-PA) treatment was deemed appropriate by Cardiovascular Surgery (CVS) and the patient was followed up in the CVS intensive care unit. During the intensive care unit follow-up, the patient's abdominal tenderness and abdominal pain persisted and diagnostic laparotomy was planned. During diagnostic laparotomy, no acute findings were found in the foreground and evaluation for possible vasculitic processes by surgical specialties was considered in the foreground and t-PA infusion was stopped and the patient was transferred back to the Rheumatology clinic. Renal biopsy was performed diagnostically due to > 0.5 gram/day proteinuria and the renal biopsy report showed global sclerosis in 4 of 32 glomeruli sampled, segmental proliferation in 5–6 glomeruli, thrombus in the arcuate artery, immunofluorescence findings and IgA-nephropathy findings. The pathology report of the punch biopsy, which was concluded simultaneously and previously performed by the Dermatology clinic, showed fibrinoid necrosis in the vascular structures in the upper and middle dermis, endothelial swelling, and severe polymorphic leukocyte infiltration including sparse eosinophils in both vascular walls and stroma. It was evaluated as vasculitis as a result of histomorphologic findings. The patient was started on Warfarin as anticoagulant, Ramipril for antiproteinuric effect, Methylprednisolone 0.5 mg/kg/day as immunosuppressive (with a plan to taper off 4 mg at 2 week intervals) and Cyclophosphamide + MESNA. After the treatment protocol, the patient's purpuric rash and necrotizing lesions showed significant clinical regression, arthralgia and intestinal angina were not detected again, and acute phase reactants and proteinuria were found to be completely normal in follow-up. Cyclophosphamide + MESNA was discontinued at the end of 6 cycles after the doses were completed, Methylprednisolone was discontinued with slow taper and Mycophenalate Mofetil was started with titration. The patient is followed up in outpatient clinic as in remission under Mycophenalate Mofetil treatment. 3. Discussion The present case is presented to emphasize the importance of approaching the patient with rash, elevated acute phase reactants and thrombus etiology in the light of clinical clues and anamnesis. Although IgA-vasculitis is mostly seen in the pediatric population, it can also be seen in the adult population. It has been shown in the literature that the incidence peaks seasonally, especially in the winter season when upper respiratory tract infections are also common( 2 ). Although upper respiratory tract infections, drug use, insecticides and immunization play a role in the etiology, it has been reported in the literature that leukocytoclastic vasculitis and hypersensitivity vasculitis may lead to leukocytoclastic vasculitis and hypersensitivity vasculitis, albeit rarely, especially when paracetamol is considered ( 3 ). Clinically, especially polyarthralgia, abdominal cramps and intestinal angina, palpable purpura, microscopic hematuria secondary to renal involvement and proteinuria usually not at nephrotic level can be seen in IgA-vasculitis ( 4 ). Although palpable purpura, polyarthralgia and proteinuria were observed at presentation, microscopic hematuria and abdominal cramps were not observed and in addition, diffuse thrombi were found on imaging. Although thrombosis can be seen in many diseases such as vasculitis, malignancies, connective tissue diseases and hereditary causes, thrombosis associated with IgA vasculitis and especially cases of IgA vasculitis presenting with thrombus are rarely encountered in the literatüre ( 5 ). In the present case, we wanted to emphasize the importance of clinical findings and systemic approach. IgA-vasculitis can also be seen in adulthood, albeit less frequently, and does not always present with the typical clinical tetrad of abdominal cramping, arthralgia, palpable purpura and renal involvement. Cases of IgA-vasculitis with widespread thrombus formation are rare. The importance of evaluating localized findings from a systemic point of view and considering all rare systemic causes while approaching systemic findings from an etiological point of view and close analysis of clinical findings and observation in the process of diagnosis and early treatment is understood. Declarations Conflict of Interest The author declare that there is no conflict of interest. Author Contributions M.A.: conceptualization, investigation, methodology, analysis, interpretation of data, writing-original draft preparation and writing- review and editing Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Ethical approval All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Decloration of Helsinki and its later amendments or comparable ethical standards. Informed consent Informed consent was obtained from our patient to publish her clinical data References Georgesen C, Fox LP, Harp J. Retiform purpura: A diagnostic approach. J Am Acad Dermatol. 2020;82(4):783-96. Farley TA, Gillespie S, Rasoulpour M, Tolentino N, Hadler JL, Hurwitz E. Epidemiology of a cluster of Henoch-Schonlein purpura. American Journal of Diseases of Children. 1989;143(7):798-803. Harris A, Burge SM. Vasculitis in a fixed drug eruption due to paracetamol. Br J Dermatol. 1995;133(5):790-1. Audemard-Verger A, Pillebout E, Guillevin L, Thervet E, Terrier B. IgA vasculitis (Henoch-Shönlein purpura) in adults: Diagnostic and therapeutic aspects. Autoimmun Rev. 2015;14(7):579-85. Pillebout E, Thervet E, Hill G, Alberti C, Vanhille P, Nochy D. Henoch-Scho [Combining Diaeresis] nlein Purpura in Adults: outcome and prognostic factors. Journal of the American Society of Nephrology. 2002;13(5):1271-8. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6776460","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":470080563,"identity":"310c6ca1-1742-4164-94e5-6ee3225628f4","order_by":0,"name":"Murat AY","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2UlEQVRIiWNgGAWjYBADHn72BiBlYEGk+gMMDHKSPQdAWiSI12JscCMBxCRCi+6M3IefP9QcTtxw8/nVDT8KJBj427sT8Goxu5FuLHHg2OHEmbdzym72AB0mcebsBgJa0hgkDrAdTuy7nZN2gweoxUAil6AW5h8H/h1ObLh5Ju3mHyK1sEkcbDtsLHCD/dht4mw584zN4mxfOjCQc9huyxhI8BD2y/E05hsV36yBUXn82c03f2zk+Nt78WuBgmYg5jEAsXiIUQ4CdUDM/oBY1aNgFIyCUTDCAABF7E64yGUACgAAAABJRU5ErkJggg==","orcid":"","institution":"Kutahya State Hospital","correspondingAuthor":true,"prefix":"","firstName":"Murat","middleName":"","lastName":"AY","suffix":""}],"badges":[],"createdAt":"2025-05-29 12:23:31","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6776460/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6776460/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":84692556,"identity":"cf621dbc-2290-4733-8798-e8204793aa57","added_by":"auto","created_at":"2025-06-16 10:04:46","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":394033,"visible":true,"origin":"","legend":"\u003cp\u003eNecrotizing lesions with crusts on bilateral lower extremities (left) and palpable purpura (right)\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6776460/v1/4be6c38a824c380f577fd758.png"},{"id":84692080,"identity":"197b27a5-93bb-41eb-b5c2-5d3802d33f40","added_by":"auto","created_at":"2025-06-16 09:56:46","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152675,"visible":true,"origin":"","legend":"\u003cp\u003eThrombus at the origin of the left subclavian artery distal to the arcus aorta\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6776460/v1/0c3160c211bdc37f3aa8be96.png"},{"id":84693393,"identity":"3bb7a527-d09e-41c3-b56e-109c3b8cc7e7","added_by":"auto","created_at":"2025-06-16 10:12:46","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":160659,"visible":true,"origin":"","legend":"\u003cp\u003eInfarct areas in the lower pole and medulla of the right kidney\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-6776460/v1/c4012663f48411c2b2a68810.png"},{"id":97139609,"identity":"ad3eeb69-9174-4607-a257-cf7488fc128b","added_by":"auto","created_at":"2025-12-01 10:00:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1291838,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6776460/v1/0bd8101d-5000-41c3-b303-028ea43660e7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"A Patient Presenting with Palpable Purpura, Necrotising Lesions and Swelling in Bilateral Lower Extremities: Case Report","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003ePurpura is a non-bleeding lesion of the skin, mucosal and serosal surfaces caused by infiltration of erythrocytes into the skin. Palpable purpura consists of red and/or purple papules or plaques that are raised from the skin, round or oval in shape, while retiform purpura is described as angular or geometric shaped lesions that can sometimes branch. Peripheral erythema may occur in lesions that develop secondary to inflammatory processes and areas of necrosis may be seen due to tissue infarction. Purpuras develop as a result of complete vascular occlusion and vascular damage in cutaneous vascular structures. Lesions may develop as a result of occlusion of cutaneous vascular structures by thrombus protein or emboli, or as a result of direct damage to the vasculature by vasculitic processes, calciphylaxis and severe opportunistic infections. Purpura size is generally expressed as 4\u0026ndash;10 mm in the literature. Palpable purpuras are most commonly found symmetrically on the lower extremities. Acute unilateral lower extremity swelling can be seen especially in cases with chronic venous insufficiency or deep vein thrombosis, while acute bilateral lower extremity edema can be seen secondary to various diseases such as dihydropyridine group calcium channel blockers, acute heart failure, acute nephrotic syndrome, acute deep vein thrombosis especially secondary to malignancies and inflammation (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIt can also be seen in ANCA-associated vasculitis, systemic connective tissue diseases, cryoglobulinemic vasculitis and IgA-vasculitis, with various drugs, infections and malignancies playing a role in the etiology, especially in the subtype of leukocytoclastic vasculitis. The decisive factor in the diagnostic approach is to first determine whether the process is limited to the skin or whether there is systemic involvement. Histopathologic confirmation is usually required, especially after a detailed anamnesis and physical examination.\u003c/p\u003e \u003cp\u003eA recent history of symptomatic drug use due to upper respiratory tract infection, the case was initially considered as limited involvement and referred to Internal Medicine and Rheumatology clinics for follow-up after the case showed signs of systemic involvement, Although typical systemic involvement findings were not observed, the observation of widespread thrombi and consequently widespread infarct areas in the imaging studies is thought to reveal the importance of approaching the case in a way to cover the spectrum from rare drug-related cases seen in the literature to systemic diseases in differential diagnoses and close follow-up of the case in processes that may require differential diagnosis and rapid treatment.\u003c/p\u003e"},{"header":"2. Case","content":"\u003cp\u003e49 years old male, no known history of chronic disease and regular medication use. The patient was admitted to the Cardiovascular Surgery clinic 10 days ago with complaints of bruising, itching and swelling in his legs. Subsequently, the patient was admitted to the Dermatology clinic with similar complaints. As a result of the evaluation of the patient and request for tests, it was learned that acute phase reactants were found to be high in the patient, infective pathologies were primarily evaluated in the patient, and coronavirus disease (COVID) polymerase chain reaction (PCR) was found to be negative. As a preliminary diagnosis, drug-associated vasculitis, hypersensitivity vasculitis, Cutaneous Polyarteritis Nodosa (PAN) and Henoch-Sch\u0026ouml;nlein Purpura (HSP, IgA- vasculitis) were considered and after skin punch biopsy, Methylprednisolone was started at 0.5 mg/kg/day and the patient was referred to our Internal Medicine and Rheumatology clinic for diagnosis and follow-up.\u003c/p\u003e \u003cp\u003eIn the anamnesis, it was learned that the patient had a history of symptomatic treatment with pseudoephedrine, oxolamine, chlorpheniramine and paracetamol secondary to upper respiratory tract infection 15 days before the clinical presentation, but no other history of drug use. The patient's first C-reactive protein (CRP) value before steroid treatment was 146.3 mg/dL and the second CRP value after the initiation of steroid treatment was 58.1 mg/dL. His medical history revealed a smoking history of 30 pack/year and no history of rheumatologic disease or malignancy in his family history. Rheumatologic examination of the patient revealed no significant findings except morning stiffness and dyspnea. Rheumatologic physical examination findings revealed polyarthralgia, absence of intestinal angina, palpable purpura that did not fade with pressure starting from the anterior aspect of bilateral ankles and bilateral lower extremities and extending to the femur and upper extremities, and crusty necrotizing lesions on bilateral ankles. The findings of crusted necrotized lesions and palpable purpura in bilateral lower extremities found on physical examination of the patient are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The patient was interned to the clinic.\u003c/p\u003e\u003cp\u003eIn laboratory tests; CRP: 294.9 mg/dL, Sedimentation: mm/hour, creatinine: 1.1 mg/dL, Rheumatoid factor: 17.2 IU/mL, IgA: 466 mg/dL, D-dimer: 21.9 mg/L, leukocytes (WBC): 16.880 10\u003csup\u003e3\u003c/sup\u003e uL, no hypocomplementemia, Anti-ds DNA negative, ANA and ANA-blot panel negative, ANCA negative, Quantiferon negative, Antiphospholipid antibody syndrome (APS) antibodies negative, thrombophilia panel negative, proteinuria of 0.87 grams/day in 24-hour urine.\u003c/p\u003e \u003cp\u003eThoracic and abdominal tomography with contrast was ordered. Thorax tomography findings revealed a hypodense filling defect with the appearance of a floating thrombus measuring approximately 17x8 mm in the axial plane adjacent to the level of origin of the left subclavian artery distal to the arcus aorta. Abdominal tomography findings revealed a hypodense lesion measuring approximately 35x33 mm in the medial upper pole of the spleen, which was evaluated in favor of splenic infarction, and a hypodense area affecting the right kidney lower pole cortex and medulla, which was evaluated in favor of infarction. Abdominal angiography showed no additional findings and no occlusion was observed. Bilateral lower extremity doppler ultrasonography showed no evidence of deep vein thrombosis (DVT). Echocardiography, which was requested for possible infective endocarditis and myocarditis, revealed no vegetation and no additional findings.\u003c/p\u003e \u003cp\u003eThe appearance of a thrombus at the origin of the subclavian artery is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e and the findings of right renal infarction are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe patient was evaluated on the 3rd day of post-internatization follow-up due to sudden abdominal cramps and abdominal pain. Hyperlactatemia was detected and the patient was evaluated by the General Surgery clinic for possible Mesenteric Ischemia and Mesenteric Ischemia was not considered in the patient. Tissue plasminogen activator (t-PA) treatment was deemed appropriate by Cardiovascular Surgery (CVS) and the patient was followed up in the CVS intensive care unit. During the intensive care unit follow-up, the patient's abdominal tenderness and abdominal pain persisted and diagnostic laparotomy was planned. During diagnostic laparotomy, no acute findings were found in the foreground and evaluation for possible vasculitic processes by surgical specialties was considered in the foreground and t-PA infusion was stopped and the patient was transferred back to the Rheumatology clinic. Renal biopsy was performed diagnostically due to \u0026gt;\u0026thinsp;0.5 gram/day proteinuria and the renal biopsy report showed global sclerosis in 4 of 32 glomeruli sampled, segmental proliferation in 5\u0026ndash;6 glomeruli, thrombus in the arcuate artery, immunofluorescence findings and IgA-nephropathy findings. The pathology report of the punch biopsy, which was concluded simultaneously and previously performed by the Dermatology clinic, showed fibrinoid necrosis in the vascular structures in the upper and middle dermis, endothelial swelling, and severe polymorphic leukocyte infiltration including sparse eosinophils in both vascular walls and stroma. It was evaluated as vasculitis as a result of histomorphologic findings.\u003c/p\u003e \u003cp\u003eThe patient was started on Warfarin as anticoagulant, Ramipril for antiproteinuric effect, Methylprednisolone 0.5 mg/kg/day as immunosuppressive (with a plan to taper off 4 mg at 2 week intervals) and Cyclophosphamide\u0026thinsp;+\u0026thinsp;MESNA. After the treatment protocol, the patient's purpuric rash and necrotizing lesions showed significant clinical regression, arthralgia and intestinal angina were not detected again, and acute phase reactants and proteinuria were found to be completely normal in follow-up. Cyclophosphamide\u0026thinsp;+\u0026thinsp;MESNA was discontinued at the end of 6 cycles after the doses were completed, Methylprednisolone was discontinued with slow taper and Mycophenalate Mofetil was started with titration. The patient is followed up in outpatient clinic as in remission under Mycophenalate Mofetil treatment.\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eThe present case is presented to emphasize the importance of approaching the patient with rash, elevated acute phase reactants and thrombus etiology in the light of clinical clues and anamnesis. Although IgA-vasculitis is mostly seen in the pediatric population, it can also be seen in the adult population. It has been shown in the literature that the incidence peaks seasonally, especially in the winter season when upper respiratory tract infections are also common(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Although upper respiratory tract infections, drug use, insecticides and immunization play a role in the etiology, it has been reported in the literature that leukocytoclastic vasculitis and hypersensitivity vasculitis may lead to leukocytoclastic vasculitis and hypersensitivity vasculitis, albeit rarely, especially when paracetamol is considered (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Clinically, especially polyarthralgia, abdominal cramps and intestinal angina, palpable purpura, microscopic hematuria secondary to renal involvement and proteinuria usually not at nephrotic level can be seen in IgA-vasculitis (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Although palpable purpura, polyarthralgia and proteinuria were observed at presentation, microscopic hematuria and abdominal cramps were not observed and in addition, diffuse thrombi were found on imaging. Although thrombosis can be seen in many diseases such as vasculitis, malignancies, connective tissue diseases and hereditary causes, thrombosis associated with IgA vasculitis and especially cases of IgA vasculitis presenting with thrombus are rarely encountered in the literat\u0026uuml;re (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). In the present case, we wanted to emphasize the importance of clinical findings and systemic approach.\u003c/p\u003e \u003cp\u003eIgA-vasculitis can also be seen in adulthood, albeit less frequently, and does not always present with the typical clinical tetrad of abdominal cramping, arthralgia, palpable purpura and renal involvement. Cases of IgA-vasculitis with widespread thrombus formation are rare. The importance of evaluating localized findings from a systemic point of view and considering all rare systemic causes while approaching systemic findings from an etiological point of view and close analysis of clinical findings and observation in the process of diagnosis and early treatment is understood.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eConflict of Interest\u0026nbsp;\u003c/strong\u003eThe author declare that there is no conflict of interest.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e M.A.: conceptualization, investigation, methodology, analysis, interpretation of data, writing-original draft preparation and writing- review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u0026nbsp;\u003c/strong\u003eAll procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Decloration of Helsinki and its later amendments or comparable ethical standards.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInformed consent\u0026nbsp;\u003c/strong\u003eInformed consent was obtained from our patient to publish her clinical data\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGeorgesen C, Fox LP, Harp J. Retiform purpura: A diagnostic approach. J Am Acad Dermatol. 2020;82(4):783-96.\u003c/li\u003e\n\u003cli\u003eFarley TA, Gillespie S, Rasoulpour M, Tolentino N, Hadler JL, Hurwitz E. Epidemiology of a cluster of Henoch-Schonlein purpura. American Journal of Diseases of Children. 1989;143(7):798-803.\u003c/li\u003e\n\u003cli\u003eHarris A, Burge SM. Vasculitis in a fixed drug eruption due to paracetamol. Br J Dermatol. 1995;133(5):790-1.\u003c/li\u003e\n\u003cli\u003eAudemard-Verger A, Pillebout E, Guillevin L, Thervet E, Terrier B. IgA vasculitis (Henoch-Sh\u0026ouml;nlein purpura) in adults: Diagnostic and therapeutic aspects. Autoimmun Rev. 2015;14(7):579-85.\u003c/li\u003e\n\u003cli\u003ePillebout E, Thervet E, Hill G, Alberti C, Vanhille P, Nochy D. Henoch-Scho [Combining Diaeresis] nlein Purpura in Adults: outcome and prognostic factors. Journal of the American Society of Nephrology. 2002;13(5):1271-8.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palpable Purpura, Vasculitis, Thrombus, Infarct","lastPublishedDoi":"10.21203/rs.3.rs-6776460/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6776460/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective: \u003c/strong\u003eIn the subtype of leukocytoclastic vasculitis, various drugs, infections and malignancies play a role in the etiology and can also be seen in ANCA-associated vasculitis, systemic connective tissue diseases, cryoglobulinemic vasculitis and IgA-vasculitis. The decisive factor in the diagnostic approach is to first determine whether the process is limited to the skin or whether there is systemic involvement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase: \u003c/strong\u003e49-year-old male, no known history of chronic disease and no history of regular medication use. The patient was admitted to Cardiovascular Surgery and Dermatology clinics 10 days before the clinical evaluation with complaints of bruising, itching and swelling in the legs. Physical examination revealed polyarthralgia, bilateral ankles, palpable purpura starting from the anterior aspect of bilateral lower extremities and extending to the femur and upper extremities and necrotizing lesions with crusts on bilateral ankles. Computed tomography scan revealed thrombus distal to the aorta distal to the left subclavian artery origin, splenic infarction and right renal infarction. Skin punch biopsy pathology report was histomorphologically compatible with vasculitis and renal biopsy report was compatible with IgA-nephropathy. Methylprednisolone 0.5 mg/kg/day and Cyclophosphamide+MESNA were started with the diagnosis of IgA-vasculitis and she was in remission at the end of treatment and is under follow-up and treatment with Mycophenalate mofetil.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion:\u003c/strong\u003e IgA-vasculitis can also be seen in adulthood, although less frequently, and is not always preceded by the typical clinical tetrad of abdominal cramps, arthralgia, palpable purpura and renal involvement. Cases of IgA-vasculitis are rare, especially where thrombus formations are commonly observed.\u003c/p\u003e","manuscriptTitle":"A Patient Presenting with Palpable Purpura, Necrotising Lesions and Swelling in Bilateral Lower Extremities: Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 09:56:41","doi":"10.21203/rs.3.rs-6776460/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c7b83ab2-c38a-414d-9149-ae74f87ec827","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-29T18:08:25+00:00","versionOfRecord":[],"versionCreatedAt":"2025-06-16 09:56:41","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6776460","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6776460","identity":"rs-6776460","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}