tion and management of failure to thrive. Prior to his admission, the patient had been hospitalized at another institution for shortness of breath and dyspnea on exertion. Evaluation at that time revealed decompensated congestive heart failure, end-organ nephropathy attributed to his long-standing diabetes mellitus, osteomyelitis involving both feet, a monoclonal gammopathy, normochromic normocytic anemia, and evidence of malnutrition. Despite initiation of cardiac glycosides and diuretics, which minimized his cardiorespiratory problems, the patient continued to develop progressive weakness, anorexia, persistent dizziness, and severe limitations in ambulation, for which he was transferred to our institution.Physical examination revealed a cachectic, elderly, mentally alert man in moderate distress. Major findings included significant retinopathy, wet and dry rales at the base of both lung fields, an irregularly irregular cardiac rhythm, iliofemoral bruits, absence of ankle jerks, and decreased sensation to light touch along the lower extremities. Skin find¬ ings included bilateral periorbital purpura (Fig 1); ulcérations on both feet; a large bulla draining purulent material along the plantar aspect of the right great toe; and an erythematous, tender left foot. Inquiry regarding the onset of the periorbital purpura revealed that the lesions developed after a proctoscopic examination at the referring hospital.Laboratory data revealed the following abnormal values: white blood cell count, 13,500/cu mm (normal, 7.8 X 10 ± 3/cu mm); hemoglobin, 11.1 g/dL (nor¬ mal, 16 ± 2 g/dL); hematocrit, 33.9% (normal, 47% ± 5% ); erythrocyte sedimentation rate, 57 mm/ hr (normal, 0 to 10 mm/hr); serum transferrin, 160 mg/dL (normal, 210 to 375 mg/dL); blood glucose, 178 mg/dL (normal, 70 to 110 mg/dL); serum urea nitro¬ gen, 31 mg/dL (normal, 12 to 20 mg/dL); creatinine, 1.8 mg/dL (normal, 0.7 to 1.5 mg/dL); alkaline phosphatase, 329 units/L (normal, 30 to 115 units/L); calcium, 8.3 mg/dL (normal, 8.5 to 10.5 mg/dL); and albumin, 2.7 g/dL (normal, 3.0 to 5.5 g/dL). Immunoelectrophoresis disclosed an IgG level of 5,750 mg/dL (normal, 710 to 1,540 mg/dL) and an IgA level of 42 mg/dL (normal, 60 to 490 mg/dL). A urine protein electrophoresis revealed a total protein level of 0.6 g/dL, which included both albumin and trace globu¬ lin. There was no evidence of Bence Jones protein. A culture of drainage from the right great toe was positive for Staphylococcus aureus. A gallium scan of the feet yielded findings compatible with osteo¬ myelitis.A skin biopsy specimen was taken from an area of purpura lateral to the right eye (Fig 2). Special stains were performed (Fig 3).
