A 27-year-old female visited the clinic for erythematous macules on both lower legs of more than 10 years. Dermatological examination revealed erythematous mottling of the skin with irregular broken circular segments on both lower legs (Figure 1). These skin lesions improved in summer, and are exacerbated by cold. There was no pain, tingling or paresthesia. Notably the patient also presented with slurred speech, but was without other neurological deficeit. She did not recall any specific event associated with or causing her slurred speech.
Two months later, she was admitted to another Hospital for sudden onset of vertigo and vomiting. Her family revealed that the patient had an episode of vertigo, right arm weakness at the age of 17 and slurred speech noticed since then. Erythematous netlike lesions on her lower legs appeared in the following years. Patient also denied any drug or allergy history. There was no history of hypertension, diabetes, stroke among her immediate family members.
Histopathology of the skin biopsy from lower legs revealed a predominantly perivascular mononuclear cells infiltration and extravasation of RBC in the upper dermis. Dermal vessels did not show endothelial swelling, fibrinoid degeneration or necrosis. there was no panniculitis (Figure 2).
Complete blood count and differential count(CBC & DC), antinuclear antibody(ANA), anticardiolipin antibody, cryoglobulin were all negative. SMA-14, CBC, D/C, prothrombin time, activated partial thromboplastin time, ESR, electrolytes(Na, K, Cl), were all within normal limit. Cryoglobulin and anticardiolipin antibody were again negative.
MRI showed left pons hypersignal density indicating new pontine infarction (Figure 3) and left thalamus hyposignal density suggesting old thalamic infarction (Figure 4). Based on finding of MRI and neurological examination, an old thalamic infarction and a new pontine infarct were diagnosed.
|Figure 1. Erythematous mottling of the skin with irregular broken circular segments on both legs|
|Figure 2. Perivascular mononuclear cells infiltration and extravasation of RBC in the upper dermis|
|Figure 3. Left pons hypersignal density indicating new pontine infarction|
|Figure 4. Left thalamus hyposignal density suggesting old thalamic infarction|