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She is psychiatrically stable, the lesions are not reproducible by injection of red cells, and histologically her lesions show vasculitis. However she has had more severe internal involvement (especially the respiratory tract) than is usual in this syndrome (Hersle & Mobacken, 1969). The evolution and appearance of this lady's lesions justify the designation 'Painful bruising syndrome' (Gardner & Diamond, 1955).
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During the past year there has been a dramatic reduction of new lesions by the periodic use of plasmapheresis (Dr C.Spry). However until recently the general course of her disease has been essentially unafFected by any of the following (in chronological order): antihistamines, antituberculous chemotherapy, antibiotics, dental clearance, corticosteroids, dapsone, azathioprine, phenformin and ethyloestrenol, dye-and preservative-free diet and Intal. This patient's episodes of severe airways obstruction have partially responded to parenteral antihistamine, hydrocortisone and adrenalin. Similarly intradermal injections of the patient's red cells, polymorphs, lymphocytes and whole of Sephadex-fractionated serum also failed to reproduce the lesions. (f) Functional immunological tests: intradermal tests to trichophytin, candidin and bacterial antigens were negative.
Painful bruising syndrome skin#
(e) Immunofluorescence (direct) of the skin biopsy, including very early lesions, negative. Barium swallow showed soft tissue swellings during an episode of dysphagia. (d) Radiological: chest X-ray at various times has shown linear shadows consistent with resolving alveolar haemorrhages. (c) Microbiological: no significant growth from skin, stools or urine. Total haemolytic complement, C 3, C i esterase inhibitor, ASO titre, complement fixation tests to brucella and filaria.
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Numerous attempts to identify a cause have been unrewarding, (a) Haematological: haemoglobin often low (iron deficiency or normochromic normocytic) white cell count, platelet count, ESR, clotting screen, fibrinolytic activity and viscosity all normal, (b) Biochemical and Serological, The following are normal or negative: liver function tests, proteinĮlectrophoresis, immunoglobulins, cryoglobulins, cold agglutinins, syphilis serology, DNA antibodies. Histology of skin lesions on several occasions has consistently shown a leukocytoclastic angiitis, with fibrinoid change in small blood vessels at all depths in the dermis and subcutaneous fat. She has been consistently psychiatrically stable. She had a tonsillectomy at the age of 15. She has otherwise been in good health, and had 5 normal pregnancies. Similar lesions have been seen by indirect laryngoscopy in the pharynx and larynx. They vary in size from 2 to 20 cm across, occurring particularly on the legs, trunk and arms but no part ofthe skin surface has been spared (Fig. Individual lesions last upwards of several days. The skin lesions have usually started as tender erythematous oedema, becoming purpuric and sometimes ulcerating. Less frequently she has had haemoptysis, dysphagia and abdominal pain with melaena. Since 1964 she has had recurrent episodes of tender lumps in the skin, often associated with acute dyspnoea. (32) Painful bruising syndrome with vasculitis treated by plasmapheresis DR C.KENNEDY, DR K,V,SANDERSON AND DR C.SPRY St George's Hospital, and the Royal Postgraduate Medical School, Hammersmith Hospital, London