A 60-year-old Man With Bilateral Painful Reticular Patches Of Violaceous Color On The Soles

Abstract

A 60-year-old male patient was referred for the evaluation of skin lesions on his soles which started as violaceous macules on tips of his toes three weeks before admission. Later, the lesions slowly progressed proximally to involve most of his soles in a mottled pattern and became painful. Physical examination revealed bilateral tender dark violaceous patches of reticular configuration on the soles, more prominent on the plantar surfaces of the distal phalanges of the right foot ( Figure 1). The reticular patches partly extended to the dorsal parts of the feet. A darker macule with a 0,5x1 cm sized eroded and necrotic area was seen on the plantar surface of the fifth digit of the right foot (Figure 2). Both feet were exquisitely tender to palpation. Dorsal pedal pulses were palpable bilaterally. Routine laboratory analysis revealed elevated blood urea nitrogen (61 mg/dl; normal range: 5-25 mg/dl), serum creatinine (4,33 mg/dl; normal range: 0,5 -1,10 mg/dl) and C-reactive protein levels (7,5 mg/dl normal range: 0-5 mg/dl). The patient had a 6-year history of hypertension and a 4-year history of diabetes mellitus which had been managed with antihypertensives and oral antidiabetics, respectively. His medical history was also remarkable for a coronary artery bypass graft (25 years ago), a transient left upper extremity weakness (2 years ago) and right carotid artery stent (7 months ago). Three months ago, he was admitted by the Neurology Department for acute-onset paraplegia and slurred speech and was diagnosed as a cerebrovascular accident. During his hospitalization in neurology, a nephrology consultation was obtained due to persistently elevated serum creatinine levels (2,10 to 2,69 mg/dl; normal range: 0,5 -1,10 mg/dl) and the patient