A 90-year-old white man presented with a 4-day history of asymptomatic purpuric macules and papules on his extremities, including his hands and feet. He had a history of type 2 diabetes mellitus, hypertension, peripheral vascular disease, and a bioprosthetic mitral valve replacement. He was afebrile, and no new heart murmurs were noted.
Physical examination revealed numerous purpuric macules and papules on the distal region of both forearms, the lower extremities, and the palmar surfaces of the hands and fingers (Figure 1). The lesions were nontender to palpation. A biopsy specimen was obtained from one of the forearm lesions (Figure 2 and Figure 3).