Leukocytoclastic vasculitis (LV) is a systemic inflammatory disorder involving mostly the small vessels characterized by segmental angiocentric neutrophilic inflammation, endothelial cell damage and fibrinoid necrosis. LV is related to a variety of clinical situations. We present one of a unique case of LV complicated by acinetobacter pneumonia.
87Y M from nursing home with h/o ventilator dependant respiratory failure status-post tracheostomy was sent for evaluation of skin lesions, respiratory distress and fever. The skin of the upper extremities and torso had erythematous macules and palpable purpura with advanced lesions showing hemorrhagic bullae and ulcerations. Chest X-ray had an infiltrate. Blood and sputum cultures grew multi-drug resistant (MDR) Acinetobacter Baumannii. Association of any drug with skin lesions was ruled out and the tests for rheumatological and viral panel came out negative. The biopsy of skin lesions showed leukoclastic vasculitis with bullae-fluid showing neutrophilic and lymphocytic infiltrates without eisinophils growing MDR-Acinetobacter. Patient was started on Polymyxin-B, but pneumonia worsened complicated by pnemothorax. Chest tube was placed, patient's clinical situation continued worsening and later on he died with this infection.
In LV, the primary goal is to identify the causative agent, be it a drug or a microbe. Common conditions should be excluded first with discontinuing a potential drug. A thorough physical examination, chest X-ray, ESR and biochemical tests should be ordered. Skin biopsy, cultures, rheumatological and viral panels might be indicated .E. Coli, Streptococcus, Influenza, Hepatitis B, herpes simplex, CMV, parvovirus, HIV and malaria have earlier been described associated with LV.
Although Acinetobacter has not been reported before associated with LV, In our patient the clinical, histopathological, and microbiological association, and also the absence of other causative agents all confirm that Acinetobacter was associated with the leukocytoclastic vasculitis.
Leukocytoclastic vasculitis associated with Acinetobacter pneumonia is a rare but potentially lethal complication of Ventilator-associated pneumonia (VAP). A patient involving MDR Acinetobacter strains with leukoclastic vasculitis should prompt an infection control involvement to halt a potentially lethal epidemic.
Shahbaz Ahmad, No Financial Disclosure Information; No Product/Research Disclosure Information