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.