A Young Woman With Ulcerated Skin Lesions on Her Lower Extremities.
A Young Woman With Ulcerated Skin Lesions on Her Lower Extremities.
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一名下肢皮肤溃烂的年轻女子。
DOI：
10.1093/cid/ciz1012
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发表时间：
2020
期刊：
影响因子：
--
通讯作者：
Simmons,JasonD
中科院分区：
文献类型：
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作者：
StankiewiczKarita,HelenC;StankiewiczAcosta,Carolina;Simmons,JasonD
一名34岁的女性患者在急诊科就诊时出现了5天的进行性、疼痛、溃烂的腿部皮损。她报告说，她主观发烧，大腿上有疼痛的结节，手脚肿胀。她过去的病史包括3岁时的特发性免疫性血小板减少性紫癜。她出生并继续居住在巴拉圭，在那里她是一名会计。她拒绝国内或国际旅行；其他社会和家庭历史没有贡献。经检查，患者发热，生命体征正常。多发性紫斑和坏死性溃疡边缘不规则，弥漫分布于她的四肢各处(图1A和1B)。此外，她的面部和耳垂有皮肤弥漫性渗透，手脚浮肿，大腿上有两个触痛的红斑皮下结节(图1C-E)。她的身体检查的其余部分并不引人注目。实验室检查显示，白细胞计数为10000个/毫升(30%淋巴细胞、65%中性粒细胞、1%嗜酸性粒细胞)，激活部分凝血活酶时间为49秒(正常范围，25-35秒)，纤维蛋白原424毫克/分升(正常范围，150-350毫克/分升)，心磷脂抗体免疫球蛋白M 143个(阴性-lt；12个IgM磷脂单位)，免疫球蛋白G 170个(阴性-lt；12个免疫球蛋白磷脂单位)，狼疮抗凝剂阳性。蛋白S、蛋白C、抗凝血酶、人类免疫缺陷病毒抗原/抗体、血清性病实验室检测均为阴性。她的小腿上有一处溃烂病变，取了活检标本，微生物学和组织病理学检查结果如图2所示。你的诊断是什么？
A 34-year-old woman presented to the emergency department with a 5-day course of progressive, painful, ulcerated lesions on her lower extremities. She reported subjective fevers, painful nodules on her thighs, and swelling of her hands and feet. Her past medical history included idiopathic immune thrombocytopenic purpura at age 3. She was born and continued to reside in Paraguay where she was working as an accountant. She denied domestic or international travel; other social and family history was noncontributory. On examination, the patient was afebrile with normal vital signs. Multiple purpuric macules and necrotic ulcers with irregular margins were diffusely scattered throughout her lower extremities (Figure 1A and 1B). Additionally, she had diffuse infiltration of the skin on her face and earlobes, edema in her hands and feet, and 2 tender and erythematous subcutaneous nodules on her thighs (Figure1C–E). The rest of her physical examination was unremarkable. Laboratory studies revealed a white blood cell count of 10 000 cells/mL (30% lymphocytes, 65% neutrophils, 1% eosinophils), activated partial thromboplastin time of 49 seconds (normal range, 25–35 seconds), fibrinogen 424 mg/dL (normal range, 150–350 mg/dL), cardiolipin antibody immunoglobulin M of 143 (negative< 12 IgM phospholipid units) and immunoglobulin G of 170 (negative< 12 IgG phospholipid units), and lupus anticoagulants were positive. Protein S, protein C, antithrombin, human immunodeficiency virus antigen/antibody, and serum Venereal Disease Research Laboratory test were negative. A biopsy specimen was obtained from an ulcerative lesion on her lower extremity, and microbiological and histopathological evaluation showed the findings depicted in Figure 2. What is your diagnosis?