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JAMA Clinical Challenge

Patient With a Rash, Abdominal Pain, and Weight Loss

Figure 1.
Florid erythematous maculopapular blanching rash over anterior chest, with areas of confluence.

Figure 2.
Coronal CT image demonstrating wedge-shaped splenic infarction and minor thickening of large bowel in right iliac fossa. Click on image to view a larger version.

Brent O'Carrigan, BSc, MBBS(Hons), MMed(Clin Epi)
A 49-year-old man presents with right iliac fossa pain of 36 hours' duration. He reports loss of appetite, weight loss, and increasing lethargy over the preceding 10 months with intermittent constipation but no other symptoms. He describes asymmetric altered sensation in his distal lower limbs with left worse than right. The patient smokes, has a history of illicit amphetamine and cannabinoid use, and acquired tattoos in a correctional facility. Past medical history is remarkable for an idiopathic splenic infarction 6 months ago. On physical examination, he is cachectic and he has right iliac fossa tenderness and percussion tenderness. He has a demarcated, erythematous maculopapular rash across his torso and limbs ( Figure 1). Neurological examination reveals an asymmetric lower limb sensory neuropathy.

Laboratory findings include leukocytosis (white blood cells, 16 900/µL), elevated inflammatory markers (C-reactive protein, 109 g/L; erythrocyte sedimentation rate, 27 mm/h), elevated rheumatoid factor (269 IU/L), low C3 and C4 (0.24 and <0.05 g/L, respectively), and a low titer of atypical perinuclear antineutrophil cytoplasmic antibody (ANCA), not selective for either proteinase 3 or myeloperoxidase. Double-stranded DNA and extractable nuclear antibodies are negative. Cryoglobulins and serology for human immunodeficiency virus, hepatitis B, and hepatitis C are negative. Renal function is normal with normal urinary sediment. Abdominal computed tomography reveals mild thickening of the ascending colon and the previously documented splenic infarction ( Figure 2).

See the full article for an explanation and discussion.

Author Affiliations: Dr O'Carrigan ( b.ocarrigan{at}gmail.com) and Dr Cheong are affiliated with the Central Clinical School, University of Sydney, Camperdown, Australia.