Putting Your Finger on Petechiae

culaneous signs 01 cardiopulmonary disease Putting Your Finger on Petechiae* Glenn D. Goldstein, M.D .; and Marvin Dunn, M.D ., F.C.C.P.

A60-year-old caucasian man with previous myocardial infarction and cerebral vascular accidents presented in the emergency room with recent onset left arm and leg weakness. The patient also complained of right arm pain . He denied chest pain, shortness of breath, headaches, or visual changes. No carotid bruits could be auscultated. During his evaluation in the emergency room the patient developed ventricular tachycardia that was successfully treated by electrical cardioversion and intravenous antiarrhythmic therapy. After being admitted to the coronary care unit, the patient developed reddish-blue petechiae over the distal phalanges and palms of both hands . (Fig 1)At no time was there a diminution of his pulse rate in the upper extremities. What is the diagnosis? a) Subacute bacterial endocarditis b) Vasculitis c) Mural thrombus emboli d) Drug reaction ·From the University of Kansas ColIege of Health Sciences and Hospital. Kansas City. Kansas. Reprint requests : Dr. Dunn. University of Kansas Medical Center, 39th and Rainbow. Kansas City . KS 66103

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Answer: The diagnosis

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(c), Mural thrombus emboli

This 60-year-old man had an anterior myocardial infarction nine years ago. Serial electrocardiograms revealed persistent ST-T wave elevation in leads VI through V, (Fig 2). These findings suggested left ventricular aneurysm which was confirmed by echocardiogram. A mural thrombus was visualized also. The patient had been on therapy with warfarin (Coumadin) for several years; however, his admitting protime was 15 seconds with a control of 11 seconds. The emboli could have been dislodged due to inadequate anticoagulant therapy or loosened by electrical cardioversion during his ventricular tachycardia. This would mean the emboli showered the carotid and subclavian arteries since no other skin lesions were seen. This would account for the stroke symptoms and the skin lesions to the upper extremities. The patient subsequently was treated with intravenous heparin sulfate with resolution of all skin lesions within 24 hours and improvement of his left-sided weakness. Subacute bacterial endocarditis (SBE)is an insidious infection characterized by fever, new murmur, and skin manifestations. I The cutaneous signs associated with SBE include splinter hemorrhages of the nails, con-

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junctival and palatal petechiae, Janeway lesions, purpuric lesions, Roth spots (oval pale areas surrounded by hemorrhage near the optic disc), and Osler's nodes." Systemic vasculitis could account for the patients CVA symptoms, as well as the purpuric lesions of the skin. However, the well-documented ischemic heart disease and cerebrovascular history would help to exclude this choice. A drug reaction could also produce a vasculitis of the skin, but would not account for the symptoms of stroke. This patient had been on Coumadin therapy for several years. Coumadin does produce purpuric lesions which can become bullous and eventually cause necrosis of the skin. However, this usually occurs within ten days after starting anticoagulant treatment. The sites of predilection are the breasts , hips, thighs, and buttocks. 3 REFERENCES 1 Wyngaarden ]B, Smith LH. Cecil textbook of medicine , 16th ed. Philadelphia : W. B. Saunders ce.. 1982; 1461 2 Fitzpatrick TB, et al. Dermatology in general medicine, 2nd Ed . New York: McGraw-Hill, 1979; 1401-02 3 Caldwell EH , Stewart S. Skin necrosis as consequence of Coumadin therapy. Plastic Reconst Surgery 1983; 72:231-33

PuttIng Your FInger on Petechiae (GoId8te/n. Dunn)