Blood culture-negative infective endocarditis presenting with atypical dermatologic manifestation: A rare case report and review of the literature

Infective endocarditis (IE) rarely presents with cutaneous manifestations due to earlier diagnosis and treatment. We present a case of middle-aged male patient presenting with an erythematous papular rash in the upper extremities and left knee, further progressing into painful ulcers with crusted and necrotic center in the arms and fingers. These cutaneous lesions were further followed by shaking chills and fever, which brought the patient to our hospital. Laboratory evaluation revealed elevated ESR (erythrocyte sedimentation rate) and C-reactive protein. Blood cultures taken were negative. Biopsy of the skin lesions were consistent with cutaneous leukocytoclastic vasculitis, and the gram smear revealed gram-positive cocci. The patient developed dyspnea and chest pain, which raised suspicion for IE. TEE (transesophageal echocardiography) demonstrated mild LV diastolic dysfunction, 1+ tricuspid valve regurgitation, mild mitral regurgitation, and vegetation-like lesions on the surface of mitral valve leaflets, consequently IE was confirmed. In conclusion, clinicians must look carefully for skin manifestations in cases with high likelihood of IE, even when other typical symptoms are absent.

Tofacitinib Treatment of Refractory Cutaneous Leukocytoclastic Vasculitis: A Case Report

Introduction

To date, there is no treatment with proven efficacy for cutaneous leukocytoclastic vasculitis (CLV). Several reports have suggested that CLV responds favorably to corticosteroids, colchicine, nonsteroidal anti-inflammatory drugs (NSAIDs), azathioprine, and hydroxychloroquine (HCQ). To the best of our knowledge, the oral small molecule Janus kinase inhibitor, tofacitinib, plays an important role in the treatment of autoimmune and inflammatory diseases. Therefore, tofacitinib may be a prospective therapy in patients with CLV.

Case Presentation

A 29-year-old woman presented to our hospital with a 5-year history of symmetric skin lesions mainly affecting both lower extremities. The results for anti-neutrophil cytoplasmic antibodies (ANCA), anti-extracted nuclear antigens (ENA) autoantibodies, anti-double-stranded deoxyribonucleic acid (dsDNA) antibodies, and antinuclear antibodies (ANA) were all negative. The definite diagnosis of CLV was determined by a skin biopsy. However, the patient exhibited a poor response to prednisone, HCQ, methotrexate, colchicine, azathioprine, and tripterygium wilfordii polyglycoside tablets (TGTs) treatments. She was then treated with oral tofacitinib (5 mg twice daily) and oral prednisone (25 mg daily).

Outcomes

Her skin lesions gradually improved over a period of 4 weeks. Two months later, the skin ulcers completely resolved. No evidence of recurrence of skin ulcers was observed during a 6-month follow-up.

Conclusion

We present the first case of a female patient receiving short-term tofacitinib therapy for refractory CLV. Tofacitinib may be a promising oral alternative for patients with CLV. However, its efficacy and safety require further appraisal through clinical trials.

[Acute hemorrhagic edema of infancy: alarming lesions of a benign condition. Case report]

We report a case of acute hemorrhagic edema of infancy in an 18-month-old boy after an episode of otitis media. The clinical presentation begins with skin erythematous macules on the thighs, followed by purpuric lesions in arms, legs, and ankle edema. It was initially interpreted as urticaria, whereby steroids were indicated. However, the clinical feature was acute hemorrhagic edema of infancy, a benign leukocytoclastic vasculitis that occurs in children between 4 and 24 months of age and is characterized by fever, large purpuric palpable target-like skin lesions affecting the face, lobes of the ears, limbs and frequently associated with edema. Differential diagnosis includes erythema multiforme, hemorrhagic urticaria, drug- induced vasculitis, Kawasaki disease, infected eczema, sepsis (either meningococcal or non-meningococcal) and child abuse. Some of them have risk of mortality. Management is conservative, however, steroids may be a therapeutic option.

Antituberculosis therapy-associated cutaneous leukocytoclastic vasculitis

Antituberculosis therapy-associated cutaneous leukocytoclastic vasculitis (CLV) has been rarely reported. We describe a case of CLV induced by rifampicin and pyrazinamide. A 14-year-old male diagnosed with disseminated tuberculosis developed purpuric lesions after 1.5 months of treatment. Histopathology was consistent with leukocytoclastic vasculitis. Skin lesion improved after cessation of the two drugs and treatment with corticosteroids.