Bacterial Endocarditis Complicated by Leukocytoclastic Vasculitis

Abstract

A 29-year-old woman who underwent dental extraction 1 month before her presentation with painful purpuric skin lesions that progressed to necrotic ulcers over the buttocks and lower extremities (Figure 1A ). Physical examination demonstrated new pansystolic murmur grade IV/VI at the apex of the heart and splinter hemorrhages. Initial laboratory testing was pertinent for elevated inflammatory markers, low C3 and C4 levels, positive Rheumatoid factor, positive p-ANCA (titer 1:5120) and positive anti-serine proteinase 3. Blood cultures grew Staphylococcus epidermidis.A transesophageal echocardiogram confirmed the presence of large vegetation on the mitral valve associated with severe mitral regurgitation (Figure 1B). Skin biopsy demonstrated small- and medium-sized vessels with reactive endothelium and surrounding acute inflammatory cells as depicted between the arrows in Figure 1C, on background of fibrinoid necrosis and focal extravasated red blood cells and nuclear dust, all suggestive of leukocytoclastic vasculitis.