Updated: 12/7/2018

Leukocytoclastic Vasculitis

Review Topic
1 1
  • A 56-year-old woman presents to her dermatologist’s office for a rash on both of her shins. She reports that this rash started a day ago and that her legs ache also. She has had low-grade fevers and some recent weight loss. Her past medical history includes diabetes, hypertension, and systemic lupus erythematosus, which was diagnosed a year ago but has not had a flare in over 6 months. On physical exam, she has bilateral symmetric non-blanching palpable purpura. Several lesions on her right shin have coalesced into violaceous plaques. She is started on steroids.
  • Clinical definition
    • leukocytoclastic vasculitis (LCV)
      • an inflammatory small vessel vasculitis that affects the skin (cutaneous) and/or other organs (systemic)
  • Epidemiology
    • incidence
      • cutaneous LCV > systemic LCV
    • demographics
      • female > male
    • location
      • skin
  • Etiology
    • idiopathic (50% of cases)
    • autoimmune disease (15-20% of cases)
    • drugs (i.e., levamisole-tainted cocaine)
    • infections (i.e., group A streptococcus, hepatitis B, or hepatitis C)
    • malignancy
  • Pathogenesis
    • immune complex deposition in small vessels causes complement activation
    • this releases neutrophils and vasoactive amines, causing inflammation, vessel destruction, and extravasation of red blood cells
      • the “violaceous” purpura is caused by this extravasation of red blood cells
  • Associated conditions
    • Henoch-Schönlein purpura
      • occurs in children
  • Prognosis
    • recurrence occurs in up to 10% of patients
  • Symptoms
    • rash
      • occurs 7-10 days after infection, exposure to a medication, or 6+ months after onset of autoimmune disease
      • occurs on dependent areas of the body, such as lower extremities
      • maybe burning, painful, or pruritic
    • systemic symptoms
      • fever
      • weight loss
      • fatigue
      • myalgias
      • abdominal pain
  • Physical exam
    • symmetric, non-blanching, violaceous palpable purpura 
      • 1-3 mm in size
      • lesions may coalesce and lead to plaques, nodules, and necrosis
      • occurs on lower extremities and areas of pressure/trauma (i.e., sock lines and under compression devices)
  • Labs
    • in cases in which the cause is unknown, patients often undergo autoimmune workup, including antinuclear antibody (ANA), rheumatoid factor (RF), antineutrophil cytoplasmic antibodies (ANCA), cryoglobulins, complement levels, and hepatitis serologies
  • Skin biopsy of fresh lesions (24-48 hours old)
    • histology
      • leukocytoclasis” describes neutrophilic infiltrate, along with granulocytic debris, fibrinoid necrosis of vessel walls, endothelial swelling, and extravasation of red blood cells
    • direct immunofluorescence helps narrow down the differential diagnosis
      • immune complex deposition in small vessel walls
        • immunoglobulin (Ig) A suggests Henoch-Schonlein purpura
        • IgM may suggest cryoglobulinemia
        • C3 or IgG suggests systemic lupus erythematosus
        • negative results may suggest pauci-immune vasculitides such as ANCA-vasculitis
  • Making the diagnosis
    • based on clinical presentation and laboratory studies
  • Polyarteritis nodosa
    • distinguishing factor
      • a medium vessel vasculitis like polyarteritis nodosa presents with more subcutaneous nodules, livedo reticularis, retiform purpura, and significant ulcers
  • Medical
    • topical corticosteroids
      • indication
        • mild disease or single episode
    • systemic corticosteroids
      • indication
        • severe or recurrent disease
    • colchicine or dapsone
      • indication
        • patients who cannot receive corticosteroids, or if the disease recurs after steroid taper
  • Involvement of internal organs

Please rate topic.

Average 4.0 of 3 Ratings

Thank you for rating! Please vote below and help us build the most advanced adaptive learning platform in medicine

The complexity of this topic is appropriate for?
How important is this topic for board examinations?
How important is this topic for clinical practice?
Questions (1)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Topic COMMENTS (6)
Private Note