In this case challenge, Dr Rohini Handa presents a new case open for interpretation. Here, he describes a patient reporting with arthralgias and skin rash, findings from physical examinations and investigations and quizzes doctors on diagnosis and strategies that can be used to treat the patient.

Purpura in a 41-year-old lady- How to approach in the clinic?

Mrs MD, a 41-year-old lady, was referred with complaints of arthralgias and intermittent skin rash for 8-9 years. The rash was non-itchy and usually occurred on the legs and thighs (check figure). The arms and face were spared.

Prolonged standing in the kitchen aggravated the rash. There was no history of fever, weight loss, or anorexia. The patient denied any bleeding from the nose, mouth, ears or excessive bleeding during her periods. She was normotensive and non-diabetic. Physical examination was unremarkable except for palpable purpura on her legs (check figure). Heart/Chest NAD. No organomegaly was appreciated on abdominal examination. The joint examination did not reveal any synovitis or deformities.

Laboratory investigations available:

• Hb. 11 g/dl, TLC 5100 [Polys 63%, Lymphocytes 33%, Monocytes 3%, Eosinophils 1%]
• Platelets 230000
• ESR 95
• LFT: ALT/AST 31/25
• TSP/A/G 8.1/4.2/3.9
• Creatinine 0.6
• Urine NAD
• TSH 4.75
• RF positive 81.4 (<12)
• Anti-CCP negative
• ANA positive 1:3200

Disclaimer- The views and opinions expressed in this article are those of the author and do not necessarily reflect the official policy or position of M3 India.

The author, Dr. Rohini Handa is a Senior Consultant Rheumatologist from Delhi.

*The lucky winners of this case challenge will receive their copies of Clinical Rheumatology within 4-6 weeks.