31F with a variety of symptoms, mainly a rash. Struggling with addiction and a plethora of other stressful life events. This papular rash appeared on the lower legs and within two days spread up the legs. The rash was flat, not itchy, not painful. Lower legs and feet then started to swell when walking short distances and became short of breath. Was also very weak. Fingers and feet have been peeling for a couple months. Decided to go to hospital and was admitted for 6 days. At triage was tachycardic sitting there at 150bpm. Multiple ECGs done throughout stay as HR remained tachycardic at rest. Rash started to fade. Discharged with a referral to a rheumatologist as they believe this is autoimmune. Now the rash has gotten worse, it burns at the touch for example showering is very painful as it feels like my legs are on fire with the water hitting my legs. It has spread to the arms. Feet are very swollen and painful. The bottom of my feet feel raw, it hurts to walk. Being up on my feet, they swell even more and it feels like I am swelling up to my knees, it feels very tight. Generally feel very weak with sore joints and still short of breath when walking even short distances. No new medication, change in laundry, body products etc. No known allergies.
Discharge Summary:
Past medical history:
Depression
Generalized anxiety disorder
ADHD
Alcohol use disorder
Opioid use disorder
Pertinent investigations:
WBC 9.32, Hgb 109, PLT 164
Sodium 138, potassium 3.9, chloride 103, creatinine 61
ALT 50, downtrending to 34
ALP 136, downtrending to 124
Total bilirubin relatively stable at 49, direct 34
Rheumatoid factor: Less than 12 IU/mL
ANA: Negative
CANCA antibody less than 0.2
PANCA antibody less than 0.2
Anti-ENA screen: Negative
Complement C3: 0.63 g/L (low)
Complement C4 0.23 g/L
Serologies for hepatitis B, C, HIV, CMV and syphilis: Negative EBV serology: Positive for historical infection.
Urine culture positive for E. coli and Klebsiella
CXR April 10:
* Hardware internally fixating the left clavicle
* No large areas of collapse, consolidation or evidence of pulmonary edema
Venous Doppler April 13:
The veins in both lower extremities demonstrate normal compression and augmentation. There is no evidence of deep venous thrombosis.
Left lower leg punch biopsy April 13:
- Erythrocyte extravasation, slight superficial perivascular lymphohistiocytic inflammation with a few exocytotic lymphocytes, minimal spongiosis, and focal parakeratosis.
Comment: RBCs are noted in the upper dermis, but there is no evidence of vasculitis.
Stains for fungus and siderophages are negative. Consider pityriasis rosea and pigmented purpura, or some kind of allergic reaction or urticaria.
12-Lead ECG
HEART RATE: 134 bpm
P-R Interval: 128 ms
P Front Axis: 76 deg
QRSD Interval:59 ms
QT Interval: 295 ms
QTcB:441 ms
QRS Axis: 57 deg
Interpretation:
Sinus tachycardia
Ventricular premature complex