Member Forum

1.  another quick clinic query- vasculitis

Posted 05-17-2017 14:30
What would you do my wonderful colleagues?

42 you female with fibromyalgia no meds or supplements
no Tob

"rash" on feet- non tender, non pruritic- appeared one week ago as dime spot on tip of toe and now spreading over last week

wish I had pictures- clearly demarcated, purplish red patches, non blanching over tips of toes - Great toe, 2nd and 4th on R,
2 and 3 on left, some involvement in interdigital areas, biggest patch now quarter sized

I thought vasculitis and sent her to derm for bx and drew labs-
labs came back negative and all normal
I got back from derm  note stating they were planning to do bx. I got no bx results nor what plan they suggested after results back.

Patient called me and sent a portal note upset and asking for more information.
stated derm PA  had called her with bx results and per patient was told vasculitis and to use clobetasol ointment on areas
Patient contacted me wanting reassurance that the steroid ointment was the right choice and asking what did this all mean?

what would you do next? 

Melissa Weakland MD
Ballard Neighborhood Doctors
Seattle WA
IMP since 2007

2.  RE: another quick clinic query- vasculitis

Posted 05-18-2017 04:40
Hello Melissa :
I would call the dermatologist to hear directlyrics from them. Missed communication can produce bad outcomes, in this case rash not resolving. I would advise patient to take pictures, use the clobetasol for a week and return to see me  IN 1 WEEK. Since she has Fibromyalgia I would consider Rheumatology consult.
Blessings to you and your family!

Edgar Cruz
Cruz Medical Services
Clermont FL

3.  RE: another quick clinic query- vasculitis

Posted 05-18-2017 16:09

If "Vasculitis" is truly the diagnosis on the Bx report (remember to trust, but verify), in a patient with Fibromyalgia, a Rheum workup would definitely be indicated.

Even if a Rheum w/u was done in the past, given the new symptoms, it should be revisited (sooner, than later).

Hoping for a good outcome,


Milton (Moshe) Stern, M.D.
Staten Island, New York
He [Hillel] used to say: If I am not for myself, who is for me?
And if I am only for myself, what am I?
If not now when? (Avot 1:14)

4.  RE: another quick clinic query- vasculitis

Posted 05-19-2017 14:35
Vasculitis from what?  The differential diagnosis of what you describe might include connective tissue disorders, anti-phospholipid antibodies, paraneoplastic syndrome, other hypercoagulable states and cardio- or athero-embolism.  What other history and physical findings does she have?  What labs did you order?   If the lesions do resolve while she smears ointment on them, that doesn't mean clobetasol had anything to do with it.

Vahe Keukjian
Your Family Doc PC
Ghent NY

5.  RE: another quick clinic query- vasculitis

Posted 05-21-2017 18:10
Hi Melissa,

This sounds like Buerger's dx.
Cryoglobulinemia w/also be thought of but doubt from your Hx.

And her fiber might actually be due to the Buerger's.

Is her CBC, Ig levels & inflammatory markers WNL?

Steroids are a short term tx with all the assoc. issues as you know if you go with an oral.
I doubt the topical is going to do much.
Since I practice integratively, I'd edu. her on an anti-inflame. diet: eliminate all dairy, do an "oil change," anti-inflame. herbs like tumeric, resveratrol, quercitin, EGCG, ginger, POC's, omega 3s, etc.

Cindi Croft, DO
New Dimensions Family Care, PLLC
Concord, NH

6.  RE: another quick clinic query- vasculitis

Posted 05-24-2017 00:20
Distal distribution does suggest cryo- easily tested- draw a purple and green top, refrigerate, see if it clumps.
I also agree with all the other suggestions.
Vasculitis is uncommon, but LOTS of weird causes.

Peter Liepmann MD FAAFP MBA
My mission is to fix US health care
Bakersfield CA