2009 Southern Regional Meeting Abstracts

Case Report: A 57 year old man with two years history of Diabetes Mellitus presented with left great toe gangrene and rash over lower extremities for three days.He denied trauma.The skin lesions were purpuric,non itchy and nontender.Patient was on glargine insulin for his Diabetes but non compliant and had stopped taking for atleast past six months.He started on Glargine insulin after he developed the toe ulcer,just a day prior to developing the rash on the legs.The gangrenous toe was amputated and antibiotics were started for osteomyelitis confirmed by MRI.Patient was continued on Glargine insulin for glycemic control. Patient did not have fever or other systemic signs of sepsis but the purpura was worsening.Laboratory tests including CBC, renal,liver functions,C3/C4,ANA,ANCA were normal. Skin biopsy done revealed Neutrophilic Leucocytoclastic Vasculitis.As per his history since the purpura developed after restarting glargine insulin,this insulin preparation was stopped and changed to Human Regular/NPH insulin.The skin lesions regressed in the next two days and completely resolved in 2 weeks.Patient was discharged home on iv antibiotics to complete the course of 6 weeks for osteomyelitis.
Conclusion: Cutaneous leucocytoclastic vasculitis presents as palpable purpura mostly localized to the lower extremities,often accompanied by abdominal pain, arthralgia and renal involvement.The clinical diagnosis is confirmed by skin biopsy.Once diagnosis is confirmed emphasis should be made on the search for an etiological factor.The prognosis depends on the severity of internal organ involvement.In case of drug induced vasculitis, the drug should be removed immediately.Vasculitic skin lesions secondary to drugs are implicated in 10% to 30% cases.The common agents are Penicllins,Sulfonamides, Diuretics, Antihypertensives, Antiarrhythmics, Allopurinol, Cimetidine, Hydantoins. As per literature,Insulin is rarely implicated in causing leucocytoclastic vascultis.In our patient it was clearly attributable to glargine insulin since clinical improvement occurred soon after switching to another insulin preparation and also to be noted, patient did not develop any reaction to insulin Regular/NPH.