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JAMA Clinical Challenge |

Patient With a Rash, Abdominal Pain, and Weight Loss

Brent O’Carrigan, BSc, MBBS(Hons), MMed(Clin Epi); Ju Yong Cheong, MBBS, BSc(Med)(Hons)
JAMA. 2012;307(8):843-844. doi:10.1001/jama.2012.198.
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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.

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Figure 1. Florid erythematous maculopapular blanching rash over anterior chest, with areas of confluence.
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Figure 2. Coronal CT image demonstrating wedge-shaped splenic infarction and minor thickening of large bowel in right iliac fossa.
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Figure 3. A, Resected right hemicolon demonstrating acute ischemic necrosis with evidence of preceding chronic ischemia (stricture). B, Medium-sized artery of resected colon demonstrating cellular inflammatory infiltrate, intimal proliferation, and thrombosis (hematoxylin-eosin, original magnification ×40).
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