Spots of bother

Description

A 24-year-old man presented with a 2-day history of a purpuric rash affecting his lower limbs, associated with fever, malaise and anorexia. He had fistulising, stricturing Crohn's disease with an end ileostomy and two enterocutaneous fistulae requiring long-term parenteral nutrition (PN) via a single-lumen Hickman line. His only medication was analgaesia and vitamin B₁₂. He had not received regular steroids or immunosuppressive therapy for over 2 years.

On examination, he was febrile and tachycardic but not hypotensive. There were no cardiac murmurs and chest auscultation was unremarkable. His abdomen was soft and stoma output unchanged. A purpuric rash was visible on his lower limbs (figure 1). There was no meningism and examination of eyes, ears and throat was unremarkable.

Figure 1.

Purpuric rash pretreatment and post-treatment.

Blood tests revealed haemoglobin 15.2 g/dL, white cell count 11.5 (neutrophils 9.5, eosinophils 0.8)×10⁶/mL, platelet count 247×10⁹/L, erythrocyte sedimentation rate 14 mm/h, C reactive protein 82.1 mg/L, sodium 122 mmol/L, potassium 4.6 mmol/L, urea 13.8 mmol/L, creatinine 89 μmol/L, bilirubin 21 μmol/L, albumin 28 g/L, alanine transaminase 133 U/L, alkaline phosphatase 673 U/L, international normalised ratio 1.4 and activated partial thromboplastin time 42 s. Chest X-ray and urinalysis were normal. An ultrasound and CT scan of the abdomen showed a fatty liver consistent with PN-associated liver disease but no other abnormalities.

Candida glabrata was isolated from Hickman line blood cultures after 24 h incubation. The line was removed and 2 weeks of intravenous caspofungin started. The rash resolved within 48 h of treatment and inflammatory markers normalised. A transthoracic echocardiogram, vasculitis screen and complement levels were normal.

Learning points.

• Parenteral nutrition is an important risk factor for invasive candidiasis; Candida glabrata accounts for approximately 17% of positive cultures. Clinicians should remain alert to the possibility of disseminated candidiasis in susceptible patients.

• The appearance of skin lesions can be the first clinical manifestation of acute disseminated candidiasis and this diagnosis should be considered in susceptible patients presenting in this manner.