Postproctoscopic Periorbital Purpura

Abstract

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).

Periorbital Ecchymosis (Raccoon Eye) and Orbital Hematoma following Endoscopic Retrograde Cholangiopancreatography

“…Similar to that case, our patient's raccoon eye also resolved after 2 weeks. Also, in the studies reporting postproctoscopic purpura, it was a temporary sign [ 16 , 17 ]. Thus, it can be concluded that the occurrence of raccoon eye after endoscopic interventions is transient, but conditions that predispose the patients to this complication have to be determined prior to such interventions.…”

“…Tas [ 15 ] reported a case of unilateral periorbital ecchymosis in a 70-year-old man undergoing upper gastrointestinal endoscopy, which resolved after 15 days. Some researchers have also reported postproctoscopic purpura [ 16 , 17 ]. However, to the best of our knowledge, no cases of periorbital ecchymosis has been reported after ERCP in the literature.…”

Bilateral Eyelid Ecchymoses and Corneal Crystals

“…Although cysts of the ciliary epithelium and iris pigment epithelium can be demonstrated histologically in up to 50% of patients with multiple myeloma, 2 clinical ocular involvement is relatively uncommon and tends to present after the systemic diagnosis has already been made. 4 Ocular findings of multiple myeloma result from proliferation of neoplastic plasma cells leading to plasmacytomas. 2 This associated disorder results in aberrant protein deposition in various tissues of the body and usually involves a light chain-associated amyloid composed of protein AL.…”

Systemic amyloidosis associated with multiple myeloma presenting as periorbital purpura

“…Among cutaneous lesions, petechiae and ecchymoses, especially in the periorbital and facial area, are most common 5 . Deposition of amyloid within cutaneous blood vessel walls result in vascular fragility, and minor trauma may precipitate these lesions, referred to by some as “pinch purpura” 6 . Cutaneous lesions can also present as waxy papules, morphea‐like plaques, alopecia, nail dystrophies, macroglossia and pigmentary alteration 7 .…”