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JAMA Dermatology Clinicopathological Challenge
July 2017

Petechiae, Purpura, and Hemorrhagic Vesicles

Author Affiliations
  • 1College of Graduate Studies, Medical University of South Carolina, Charleston
  • 2Department of Dermatology, Medical University of South Carolina, Charleston
JAMA Dermatol. 2017;153(7):707-708. doi:10.1001/jamadermatol.2016.5965

A man in his 70s was admitted to the hospital with encephalopathy, recent falls, leukocytosis, nausea, and arthralgias. On presentation to the emergency department, he received antibiotics owing to a concern for aspiration pneumonia. He underwent a stroke workup, including transesophageal echocardiography (TEE), results of which were negative. He was noted to have a progressing cutaneous eruption during his admission, and the dermatology department was consulted. He was found to have scattered petechiae and hemorrhagic vesicles, with most concentrated on the hands and feet (Figure, A and B). Palpable purpura were noted across the extremities. Several lesions were studded with pustules. He had an enlarging bulla on his left wrist. An abrasion on his left elbow was attributed to his recent falls. The infectious disease department was also consulted, and the patient was given broad-spectrum antibiotics owing to concern about endocarditis. As part of his dermatological workup, two 4-mm punch biopsy specimens were obtained (Figure, C and D). One was sent for histopathological examination, and the other was sent for fungal, bacterial, and mycobacterial cultures. A bacterial culture swab was obtained from the tense bulla on his left wrist.

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