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Abstract: The patient cut his right knee working in a fish pond 1 month ago, and treated it with herbal medicine and then gradually developed blisters, ulcers and pain in both lower extremities. After consultation and dermatopathological biopsy, the diagnosis of allergic dermal vasculitis, a type of dermal vasculitis, was confirmed. After giving standardized medication and local care, the patient’s rash completely subsided and the ulcers healed without recurrence.
Basic information】Male, 51 years old
Disease Type】Allergic cutaneous vasculitis
Hospital】Guangdong Provincial People’s Hospital
Date of consultation】December 2020
Treatment plan】Intravenous medication (sodium methylprednisolone succinate for injection, cefuroxime sodium for injection, human immunoglobulin, cyclophosphamide for injection) + local care (physiological sodium chloride solution, povidone-iodine cream)
[Treatment period] 3 weeks of hospitalization and 6 months of follow-up after discharge
Treatment effect】The rash completely disappeared, the ulcer healed, and the disease did not recur.
I. Initial consultation
Mr. Zhang, who came to the clinic with a painful expression, was supported by his family and was walking slowly. The patient had cut his right knee while working in a fish pond one month ago, and after treatment with herbs, local pus and ulcers formed. 2 weeks ago, a dense rash gradually appeared on both lower limbs, with blisters and ulcers on some surfaces and severe pain. He was treated as “skin infection” at the local hospital, and the ulcers at the original trauma site were reduced, but the rash on both lower limbs gradually increased and extended to the extensor side of both forearms. On examination of the patient’s skin, more purpuric macules were seen on the abdomen and extremities, and blood blisters, pustules, necrosis and ulcers appeared. Auxiliary examination revealed elevated white blood cell count, neutrophil ratio, neutrophil count, C-reactive protein, and blood sedimentation, with no significant abnormalities in biochemical indexes, autoimmune indexes, or allergen testing. The clinical diagnosis was cutaneous vasculitis, presumably triggered by a previous local infection.
II. Treatment history
After communication with the patient and family, an informed consent form was signed, a skin pathology biopsy was performed, and the diagnosis of allergic cutaneous vasculitis was confirmed. An appropriate dose of glucocorticoid injection with methylprednisolone sodium succinate was given. Bacterial and fungal cultures were taken from the ulcerated surface, and cefuroxime sodium for injection was given for anti-infective treatment. After 1 week, new purpura and blood blisters were found, and the original ulcer surface was slow to heal. During the treatment period, blood glucose, blood pressure, liver and kidney function were closely monitored. After adjusting the treatment plan, there was no new rash, the original purpura gradually subsided, pain was reduced, and the original ulcer surface partially healed after 3 weeks of treatment.
III. Treatment effect
The patient was discharged from the hospital and followed up for 6 months. The ulcer was cleaned and changed daily in the local hospital according to the original plan, and the ulcer was completely healed and the rash disappeared completely after 2 weeks of discharge, leaving scar tissue and local epidermal hypopigmentation. At this time, the glucocorticosteroid dosage was gradually reduced until it was completely stopped after 6 months. One year after discharge, the patient reported no recurrence of the disease and was very satisfied with the treatment.
IV. Notes
I am glad that after a series of treatments the patient recovered from the disease and the scar tissue and epidermal pigmentation left behind are gradually decreasing. Allergic cutaneous vasculitis is a common vasculitis in dermatology. After the systematic use of glucocorticoids, attention should be paid to monitoring blood routine, biochemical and other indices to be alert to the emergence of complications such as infection, gastrointestinal bleeding, bone marrow suppression, liver and kidney function impairment. Patients should not stop or reduce the medication arbitrarily because of the reduction of symptoms before the treatment is completely finished, but must follow up regularly and adjust the treatment plan under the guidance of doctors.
V. Personal insight
The rash of this patient is more typical, mainly distributed in both lower extremities, including purpuric papules, blood blisters, necrosis and ulcers, so the diagnosis is clearer clinically, and detailed medical history should be inquired, including the history of infection and drug allergy, etc. If the causative factors can be clarified, it will help to prevent recurrence. When the disease is more serious or the efficacy is not satisfactory, the treatment plan should be adjusted in a timely manner and systematically treated with glucocorticoids, human immunoglobulin and other drugs. In addition to systemic treatment, scientific care of the ulcer surface, daily cleaning and topical anti-infective drugs are also beneficial to the healing of the ulcer surface and reduce the patient’s pain.