PMC6327711_01
Embolia cutis medicamentosa. A reticulate, nonblasnching, nonindurated, coalesced areas of mottled erythemato-violaceous patches over the right superior gluteal distribution with extension to the lateral aspect of the thigh, and right lumbar paraspinal area, with satellite lesions measuring in its maximum diameter 23 cm x 18 cm
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F1
T6, and double-sphincteric incontinence without flexor spasm or other evidence of multifocal neurological or meningeal deficits. The skin over the site of her IM injection revealed nonblanching, nonindurated, area of mottled erythemato-violaceous patches without a "palpable purpura" over the right superior gluteal distribution, with a reticulate pattern extending to the lateral aspect of the thigh and right lumbar paraspinal area, and with satellite lesions; the maximum diameter measuring 23 cm x18 cm [Figure 1] which the patient had corroborated to have coalesced and increased in size.
Magnetic resonance imaging. (a) T2-weighted sagittal spine magnetic resonance imaging revealed a longitudinally extensive altered signal intensity from T7 level to conus level with (b) (T2-weighted axial magnetic resonance imaging at T10 level) centromedullary cord involvement
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F2
Magnetic resonance imaging (MRI) revealed a longitudinally extensive, centromedullary cord involvement with altered signal intensity from T7 level to conus level in T2, fluid-attenuated inversion recovery, and short tau inversion recovery sequences without contrast enhancement with normal brain and optic nerve MRI sequences [Figure 2].
Leukocytoclastic vasculitis. (a) Epidermal infarction and subepidermal blister with inflammatory cells (H and E, x100). (b) Infarcted pilosebaceous unit (H and E, x100). (c) Perivascular and transmural neutrophilic and lymphocytic infiltrate and RBC extravasation (H and E, x200). (d) Fibrin thrombi (asterisk), destruction of vessel wall, inflammatory infiltrate, and leukocytoclasis (H and E, x100). (e) Fibrin deposition along the blood vessel wall (H and E, x400). (f) Transmural inflammatory infiltrate and leukocytoclasis (H and E, x400)
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F3
Sections of the skin biopsy [Figure 3a-f] revealed epidermal and papillary dermis infarction, with edema and extravasation of erythrocytes, the vessel walls showed fibrinoid necrosis and thrombotic occlusion of the vessel lumina with progression of vascular and perivascular necrosis, neutrophilic exocytosis, apoptotic nuclei, perivascular and transmural neutrophilic, and lymphocytic infiltrate associated with karyorrhexis in the dermal vessels all of which was consistent with leukocytoclastic vasculitis (LCV).