Dermatologic & Ocular Findings in a 27-Year-Old Male
A 27-year-old African American male presented to the office with a two-month history of intermittent chills without a fever. During this time, he experienced an unintentional weight loss of ten pounds. The symptoms progressed with the development of a painful rash of his bilateral knees. The rash was described as multiple, enlarging, red, painful, warm patches with a dry, flaky, non-pruritic outer edge. Beginning on the dorsum of his right foot, the rash spread to his bilateral shins and knees. After no resolution of the rash within two weeks, the patient sought medical attention.
Recent travel, household pets, sick contacts, sexual activity, occupational exposure, illicit drug use and over the counter or prescription medication usage was denied. He was currently employed as a postal worker. Review of systems was positive for bilateral knee pain, intermittent loose brown stools without diarrhea, fatigue, mild dyspnea on exertion and occasional nausea. One episode of non-bloody, non-bilious vomiting five days before his office visit was noted. Abdominal pain, melena, hematochezia, back pain, fever, cough, wheezing, rhinorrhea, pharyngitis, sinusitis, vision changes, eye pain, photophobia, headache, paresthesias, muscle weakness, oral or genital ulcers, or urethral discharge were all denied.
Physical examination revealed a thin, pale, non-toxic appearing male with normal vital signs. Unbeknownst to the patient, the right eye demonstrated a segmental bright red injection lateral to the cornea. (Figure 1). The conjunctiva was pale bilaterally. Over the patient’s bilateral shins and knees were multiple light red, poorly circumscribed annular patches and nodules ranging in size from three to five mm in diameter. (Figure 2, Figure 3). The lesions were non-blanchable, exquisitely tender to palpation, and warm. There was associated +1 pitting edema of the bilateral lower extremities. Residual scaling was noted along the lower aspect of the shins where the initial lesions were resolving.
Initial laboratory study results revealed a significantly elevated C-reactive protein (CRP) of 115.20 mg/L (normal < 7.48mg/L) and erythrocyte sedimentation rate (ESR) of 120 mm/hr (normal 0 -20 mm/hr). Complete blood count results demonstrated a depressed hemoglobin of 7.3 g/dL (normal 13.7 – 17.5 g/dL) and mildly elevated white blood cell count of 13.1 K/uL (normal 3.8 – 10.5 K/uL). Remaining lab tests, including human immunodeficiency virus, antinuclear antibody, rheumatoid factor, rapid plasma regain, herpes simplex virus, and Lyme testing was negative. A chest x-ray was obtained and reported as normal. A digital rectal exam revealed brown stool positive for occult blood on stool guaiac testing.