Case3. Leukocytoclastic Vasculitis(LCV)
A 77-year-old female with hypertension (HTN) presented to our emergency room with complaint of a five-day extensive rash and edema which was commenced two days after receiving her first shot of COVID19 AstraZeneca vaccine. At the admission, she had extensive palpable purpura and non-pitting edema on both lower extremities, below the knees (figure3). Rests of her examinations were unremarkable and the vital signs were within the normal range. Thus, she hospitalized and underwent further investigations. Initial laboratory tests revealed a pancytopenia (WBC: 1300/ml (neutrophil: 60%, lymphocyte: 37%), Hgb: 7.7gr/dl, Platelet: 75000/ml), elevated erythrocyte sedimentation rate (71mm/h; normal reference range (NRR) 0-30mm/hr), high lactic acid dehydrogenase(LDH) (584U/L; normal reference range (NRR) 140-280U/L), an elevated NT-PRO-BNP level (3780pg/ml) and a significantly elevated D-dimer (2.5µg/ml; normal reference range (NRR) <0.5 µg/ml), however, the rest(CRP, FBS, LFT, BUN, Cr, urine analysis, albumin, fibrinogen and coagulation tests ) were normal. The examination of peripheral blood smear (PBS), revealed Rouleaux formation and platelet aggregation (figure3). Polymerase chain reaction (PCR) test for COVID19 was negative. Patients’ characteristics are summarized in table 1.
Due to patients’ clinical manifestations and laboratory findings a possibility of vasculitis was suggested. Prednisolone (0.5mg/kg/day) prescribed and skin biopsy and further tests were ordered. HIV Ag/Ab and viral hepatitis panels were negative. Immunological screening including: C3, C4, CH50, ANA, Antids DNA, ANCA-C and ANCA-P were normal. Microscopic examination of skin specimen revealed vasculopathic changes characterized by perivascular lymphocytic infiltrate with few nuclear debris. Permeating into vessel wall with endothelia thickening and extravasated RBC. Foci of microhemorrhage in superficial dermis also identified. Purpuric vasculopathic reaction pattern of lymphocytic type in histopathology was compatible with purpric lymphocytic vasculitis diagnosis. Finally, one week after treatment rash and symptoms resolved, blood cells count improved (WBC: 4150, HB: 10.2, PLT: 110,000) and the patient was discharged.