Sir, Pityriasis rosea (PR) is an inflammatory dermatosis characterized by circular papulosquamous lesions on the trunk and extremities along the cleavage lines of body. The disease usually has a typical clinical presentation; however, atypical presentation is also seen rarely. Its typical presentation is easily recognized. Purpuric PR is one such unusual variant, which is easily misdiagnosed and reported rare in medical literature. We report a case of purpuric PR in an adult male who presented with purpuric lesions over the body. CASE REPORT A 25-year-old male presented with itchy red raised lesions which initially appeared over the trunk, followed by both lower limbs (LLs) and upper limbs (ULs) over a period of 8 days. He gave a history of fever 10 days before the onset of lesions. He gave no history of oral ulcers, photosensitivity, or joint pains. On examination, multiple well-defined, discrete to coalescing erythematous papules and non-blanchable purpuric plaques were noted over the trunk and extensor aspects of both upper and lower limbs Figure 1. The oral mucosa, hair, nails, and scalp were within normal limits. Differentials considered were cutaneous vasculitis, secondary syphilis, and infectious exanthem. The biochemical and hematological investigations were within normal limits. Viral markers and Venereal Disease Research Laboratory (VDRL) test were negative. Skin biopsy was taken from the lesion over the right leg and sent for histopathological examination (HPE), which revealed features of purpuric PR in the form of epidermal mild acanthosis, spongiosis, and hypogranulosis with overlying mounds of parakeratosis. The dermis shows perivascular lymphohistiocytic infiltrate, congested capillaries, and erythrocyte extravasates Figure 2. The patient was managed with oral acyclovir, antihistamines, and topical steroids and followed up for a period of 6 weeks with complete resolution of the lesion.Figure 1: (a-d) Multiple well-defined discrete to coalescing erythematous papules and nonblanchable purpuric plaques distributed over the lower extremitiesFigure 2: Dermis showing perivascular lymphohistiocytic infiltrate, congested capillaries, and erythrocytes extravasates (depicted by black arrowheads; HPE, ×20)DISCUSSION PR is a self-limiting papulosquamous dermatosis of unknown origin, mainly appearing in adolescents and young adults with slight predisposition in females. It has a sudden onset, with a characteristic lesion of “Herald patch” located on the trunk, with secondary eruption developing a few days later in the form of multiple pink, oval macules, with peripheral scaling collarette.1 Purpuric PR is a rare variant initially described by Hartman in 1944, characterized by round to oval purpuric macules and papules distributed over the trunk and proximal aspect of the limbs. Purpuric PR has been usually described in patients with hematological malignancies, which was not seen in our case. The abnormal morphological pattern and absence of herald patch made the diagnosis of PR difficult in this case, where histopathological evaluation helped clinch the diagnosis. Histologically, purpuric PR is characterized by patchy parakeratosis, spongiosis, superficial dermal perivascular lymphohistiocytic infiltrate, and extravasated erythrocytes without evidence of capillaritis or vasculitis. Predominant truncal distribution, nonpalpable pruritic purpura, lack of systemic involvement, lack of proteinuria, and absence of fibrinoid necrosis in HPE are characteristics that distinguish purpuric PR from vasculitis. The mainstays of therapy are topical steroids and antihistamines. Phototherapy can be useful in some cases.2-4 This case report highlights the importance of doing a detailed evaluation when dealing with a case of purpuric lesions and to keep in mind a differential of purpuric PR, which can be picked up by typical distribution of lesions and HPE. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Kishore et al. (Sat,) studied this question.