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October 2010

Lower Extremity Purpura in a Woman With Psychosis—Quiz Case

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Arch Dermatol. 2010;146(10):1167-1172. doi:10.1001/archdermatol.2010.280-a

A 50-year-old white woman visited the emergency department for dehydration, anorexia, and a vasculitic-appearing cutaneous eruption on the lower extremities of unknown duration. Her medical history included heavy smoking with subsequent chronic obstructive pulmonary disease. Despite no objective abnormalities on oral examination, when questioned about eating habits she gave a 3-month history of burning pain in her mouth that she attributed to space aliens. She also remarked that the space aliens have been controlling her dietary intake. Findings from a general physical examination showed her to be a cachectic woman who appeared older than her stated age. Cutaneous examination revealed a perifollicular, hyperkeratotic, purpuric eruption on her lower extremities (Figure 1). Histologic analysis was performed on punch biopsy specimens with hematoxylin-eosin staining (Figure 2 and Figure 3). Pertinent laboratory values showed megaloblastic anemia, low serum folate levels, and a mild elevation of liver function test results.

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