tag:blogger.com,1999:blog-9870114.post3674073314322967320..comments2024-03-10T08:41:32.400+00:00Comments on VIRTUAL GRAND ROUNDS IN DERMATOLOGY 2.0: Buttock NecrosisHumane Medicine Huihttp://www.blogger.com/profile/07113291188306363130noreply@blogger.comBlogger2125tag:blogger.com,1999:blog-9870114.post-73133289682481094152007-08-03T14:47:00.000+00:002007-08-03T14:47:00.000+00:00I agree that an atypical cutaneous presentation su...I agree that an atypical cutaneous presentation such as this (clinical gestalt-coumadin necrosis) in a nurse always raises the possibility of factitial disease (eg, injection of a sclerosant such as Talwin). However, in my view that is always a diagnosis of exclusion. I would try to exclude foreign body reaction associated with the fall with soft tissue imaging. Rather than a vasculitis I would think that an occlusive vasculopathy would be more likely the cause of what appears to be a localized infarctive subcutaneous tissue reaction in this case. Consider a trauma-reavealed hypercoagulative state such as anti-phospholipid antibody syndrome (check for cardiolipin antibodies, PT/PTT, lupus anticoagulant, ANA). Would also consider a trauma exacerbated necrotizing panniculitis such as alpha 1 antitrypsin deficiency. Would also pursue the cause of any abnormal labs (eg, elevated BUN). Would also consider excisional biopsy at edge of infarctive area, disregarding any isolated small vessel vasculitis that might be present as a non-specific reaction to the necrotic material. Good luck.Rick Sontheimerhttps://www.blogger.com/profile/01089901182170897433noreply@blogger.comtag:blogger.com,1999:blog-9870114.post-39100584352505347792007-08-02T10:36:00.000+00:002007-08-02T10:36:00.000+00:00Necrosis like this would be due to vascular occlus...Necrosis like this would be due to vascular occlusion rather than hemorrhage. What degree of heat was applied with the compress. The necrotic area is now very well defined. In the abscence of that first picture with all the bruising and considering her occupation you might think something was injected here. <BR/>If the systemic features are genuine consider a large vessel vasculitis and check her ANCAs. Otherwise we need to call in House!Dr Ian McCollhttps://www.blogger.com/profile/01609385802531645972noreply@blogger.com