Case Report Details Rare Case of SLE With Cutaneous Leukocytoclastic Vasculitis

It is rare for a patient with systemic lupus erythematosus (SLE) to present with cutaneous leukocytoclastic vasculitis, but the authors of a new case report argue it is critically important that physicians correctly diagnose such cases when they occur.

The authors published their report in The American Journal of Medicine. They explained that cutaneous involvement is common in SLE and is the first noticeable symptom in about 1 in 4 cases of SLE. Yet, they said cutaneous leukocytoclastic vasculitis is rare as an initial symptom.

In this case, a 34-year-old Hispanic woman sought medical care after experiencing a tender progressive rash on her trunk and extremities. She also had a history of polycystic ovary syndrome, hidradenitis suppurativa, rosacea, and acne vulgaris. She reported a photosensitive facial rash, hair loss, chills, and chest pain, the authors said. She also reported that a sister had SLE.

“She had extensive tender palpable purpura over the lower and upper extremities and torso, sparing mucosal membranes,” the authors wrote. “Over her cheeks and nose, she had erythematous papules, pustules, and granulomatous nodules.”

The patient also had a 2-cm patch of alopecia on her vertex scalp, they noted.

Clinicians performed several tests on the patient. Hervital signs were normal, and she had no fever. Following testing, the patient received a diagnosis of SLE on account of joint involvement, anti–double stranded DNA antibody, and nonscarring alopecia. She was treated with intravenous methylprednisone for 3 days, and then given an oral prednisone taper, along with clobetasol 0.05% cream for 14 days, colchicine 0.6 mg twice daily for 30 days, and 400 mg of hydroxychloroquine daily. After 3 months, the rash and her musculoskeletal manifestations resolved, both without recurrence.

The study researchers said most cases of cutaneous small vessel vasculitis are idiopathic or the result of an infection or medication, but they said around 15% of cases are believed to be related to an underlying connective tissue disease. About 10% to 17% of patients with SLE have cutaneous vasculitis, although the investigators said it usually is not their presenting sign.

“Skin lesion distribution on the upper and lower extremities in small vessel immunoglobulin A–predominant vasculitis has been shown to be an indicator of long-term significant renal involvement,” they wrote.

The authors said one differential diagnosis considered in the case was drug-induced lupus and vasculitis. The patient had previously taken minocycline for acne and rosacea, and she had a positive antihistone antibody test.

“However, unlike traditional drug-induced lupus, antihistone antibodies are rarely positive in minocycline-induced lupus,” the authors said. “Drug-induced vasculitis was also less likely because drug-induced vasculitis associated with minocycline is very rare, presents more as cutaneous polyarteritis nodosa, and is typically antineutrophil cytoplasmic antibody positive.”

The investigators closed by saying it is of “paramount” importance that clinicians are able to recognize cases of SLE that present with uncommon cutaneous manifestations.

“As leukocytoclastic vasculitis is not part of the clinical criteria to diagnose SLE, it is especially important to consider when other suggestive clinical features are present,” they said.

Reference

Biglione B, Zhong C, Iriarte C, Cucka B, Hoang MP, Kroshinsky D. Cutaneous leukocytoclastic vasculitis as the presenting sign of systemic lupus erythematosus. Am J Med. Published online December 7, 2022. doi:10.1016/j.amjmed.2022.11.008

‌