Over the course of a month, this 34-year-old woman had sought care at our facility—and another—on 3 separate occasions for painful bruises (visits #1 and #3) and deep vein thrombosis (DVT; visit #2). The bruises first appeared acutely on her arms (FIGURE 1A), prompting her first visit to our ED and leading to a hospital stay. Several weeks later, the patient developed new bruise-like lesions on her earlobes (FIGURE 1B), face, trunk, and lower extremities. In between these 2 visits, the patient was seen in another ED (and admitted) for right upper extremity DVT and was started on enoxaparin, followed by warfarin.
The patient had no history of trauma, but did have a 7-year history of cocaine abuse. The initial bruises appeared one week after using cocaine from a different dealer.
On her most recent visit, her vitals and physical examination were unremarkable, apart from the skin findings. Her complete blood count, complete metabolic panel, and urinalysis were unremarkable. On her previous admissions, the patient’s urine drug test had been positive for cocaine. She’d also tested positive for cytoplasmic antineutrophil cytoplasmic antibodies (c-ANCA), antinuclear antibodies (ANA), anti-double stranded DNA (anti-dsDNA), and anticardiolipin IgM.
