C2

A previously healthy 61-year-old woman with past medical history of aortic valve replacement had spontaneous eruption of a lacy, net-like erythema of her entire skin, which was especially pronounced on her arms and legs. The erythema of her lower arms disappeared within 2 minutes after immersion into a water bath at exactly 37°C. Her blood displayed the following after being placed in a petri dish:

1. Describe what you see and your leading diagnosis.


2. You noticed that two blood smear weren't analyzed. Luckily, you were there to make the first impression. Determine what is abnormal in the following slides and the situations in which you would find this abnormality. 

She experienced exertional dyspnea and dyspnea at rest. Recently she was diagnosed with EBV infection after noting a significant decrease in energy.  On physical exam you noticed scleral icterus and an enlarged spleen. She mentioned to you that she stopped taking warfarin cause she wasn’t feeling well and forgot it.


3. What systemic process is going on? Provide a reason for what incited this event. (more than one is possible)


4. What specific immunoglobulin is associated with this process?


Results on electrocardiography, echocardiography, radiography, and skin biopsy were normal, as were the differential blood count and kidney function. There was no evidence of vasculitis or the antiphospholipid-antibody syndrome.

5. What type of anemia (in regards to size) is occurring?

6. Why is the patient taking warfarin? What coagulation factors does this medicine work on?

7. You also notice the following image below. What do you think could be happening concomitantly? 

Ben T.
(Clinical Vignette adapted from NEJM)