A 47-year-old female patient presented with haematochezia and fatigue. She reported that she had 4 bowel motions, which were dark red in colour without mucus. 3 weeks prior to presentation she noticed a rash that begun on the lower limbs (including the soles) and was ascending in nature and eventually involved the trunk, buttocks and upper limbs as well as the palms. Arthralgias, dysuria and frequency accompanied the skin manifestations. A skin biopsy performed elsewhere, showed leukocytoclastic vasculitis but immunofluorescence was not performed. The patient was not taking any medication prior to the development of the rash. She was on a tapering dose of methylprednisolone since and was generally well, except for continuing dysuria and frequency.
On examination, her blood pressure was normal but she was tachycardic (114 bpm) and tachypneic (20 respirations per minute) with oxygen saturation levels on air of 95%. Her temperature was 37,3 0C. A generalized purple skin rash was evident in the aforementioned areas (Figures 1 and 2). Her abdomen was exquisitely tender in all quadrants with a degree of rebound tenderness. On rectal examination dark red blood was present. The rest of the physical examination was normal.
Significant leukocytosis (34000/mm3) was present, as were mildly elevated urea levels (56 mg/dl). Urine dipstick was positive for blood (++) and leukocytes (++) and albumin (+). On urine microscopy there were 70 leukocytes and 5 erythrocytes per high power optical field, but there were no casts. Her electrocardiogram was normal but her chest X-ray revealed moderate bilateral pleural effusions.