PMC8183367_01
Patient monographs. (a and b) Painful palpable purpura in both lower limbs during initial days of dengue illness. (c) Healing stage of impending gangrene after dengue recovery, (d) Chest X-ray posteroanterior-view with increasing perihilar vascular congestion due to left ventricular failure after dengue myocarditis
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F1
Along with bilateral pitting pedal edema, there were multiple palpable but nontender purpuric rashes present on both feet ranging in size from 2 mm to 8 mm, with fine scaling and postinflammatory hyperpigmentation with confluence toward the terminal aspect and impending gangrene [Figure 1a]. From day 3 of admission (day 9 of illness), he started experiencing severe pain in both feet, which now showed darkening in color and was tender to touch, suggesting impending dry gangrene superimposed on the purpuric rashes [Figure 1a and b]. Chest X-ray revealed features suggestive of early pulmonary edema [Figure 1d]. On follow-up visit after 7 days, his impending gangrene was not progressing and sloughing had started [Figure 1c], and he was followed up in the department of plastic surgery.
Skin biopsy photomicrographs. Low-power photomicrograph of skin biopsy (H and E, x4) (a). Superficial dermis showing focal perivascular inflammatory cell infiltrates with nuclear fragmentation (H and E x 20) (b), suggestive of leukocytoclastic or cutaneous small-vessel vasculitis, focused in the high-power micrograph and inset
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F2
A skin biopsy was obtained from the area of purpuric rashes, which revealed foci in the upper dermis with perivascular infiltration by polymorphonuclear cells with mild edema and nuclear fragmentation, suggestive of leukocytoclastic vasculitis or CSVV [Figure 2a and b].