An 89-year-old woman comes to the physician complaining of an episodic skin discoloration over the last several months. She reports scattered dark purple areas on her hands and forearms without associated pain or itching. She has no fever, chills, or recent weight loss. The patient's other medical problems include diet-controlled diabetes and right knee osteoarthritis treated with acetaminophen. Physical examination shows thin, hyperpigmented skin with several flat, dark purple ecchymotic areas over the dorsum of both forearms. Her abdomen is soft and nontender. The liver span is 6 cm without a palpable spleen. Laboratory results are as follows: Which of the following is the most likely cause of this patient's complaint?

Question

An 89-year-old woman comes to the physician complaining of an episodic skin discoloration over the last several months.  She reports scattered dark purple areas on her hands and forearms without associated pain or itching.  She has no fever, chills, or recent weight loss.  The patient's other medical problems include diet-controlled diabetes and right knee osteoarthritis treated with acetaminophen.  Physical examination shows thin, hyperpigmented skin with several flat, dark purple ecchymotic areas over the dorsum of both forearms.  Her abdomen is soft and nontender.  The liver span is 6 cm without a palpable spleen.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's complaint?

Quizplus · Accepted Answer

This patient's skin fragility, ecchymosis, and normal laboratory studies (blood counts and coagulation studies) are consistent with senile purpura. senile purpura Senile purpura (solar or actinic purpura) is a noninflammatory disorder that is most common in the elderly but can also be seen in middle-aged patients with extensive sunlight exposure. It is caused by loss of elastic fibers in perivascular connective tissue. Minor abrasions that would merely stretch the skin in younger patients can rupture superficial blood vessels in the elderly. The subsequent extravasation of blood leads to ecchymosis over vulnerable areas, such as the dorsum of the hands and forearms. Patients can have residual brownish discoloration from hemosiderin deposition. The incidence and severity are also increased in patients taking anticoagulants, corticosteroids, or nonsteroidal anti-inflammatory drugs. Senile purpura is usually not a dangerous condition and requires no further investigation. However, many older patients with severe skin fragility may require careful wound care measures following even minor lacerations. (Choice A) Bone marrow failure may present with ecchymosis by causing thrombocytopenia. Patients with bone marrow failure may also have leukopenia and anemia. This patient's normal hematologic profile makes this unlikely. (Choice B) The lupus anticoagulant is an IgM or IgG immunoglobulin that prolongs the activated partial thromboplastin time (aPTT) by binding to phospholipids used in the assay. The prolonged aPTT is a laboratory artifact; the lupus anticoagulant is not a physiologic anticoagulant but actually increases the risk of thrombosis. (Choice D) Poor platelet adhesion can occur in a variety of settings, including anti-platelet therapy (eg, aspirin, clopidogrel, eptifibatide), von Willebrand disease, or chronic kidney disease. This patient does not take any anti-platelet medications. People with von Willebrand disease typically present at a much younger age and have a family history of bleeding disorders. In addition, this patient's normal creatinine makes renal failure unlikely. (Choice E) Vitamin K deficiency depletes vitamin K-dependent clotting factors (factors II, VII, IX, and X), leading to an increase in prothrombin time (and aPTT to a lesser extent). This patient's coagulation studies are normal. Educational objective: Senile purpura usually presents with ecchymoses in elderly patients in areas exposed to repeated minor trauma (eg, extensor surfaces of the hands and forearms). It is due to age-related loss of elastic fibers in perivascular connective tissue. Senile purpura is not dangerous and requires no further evaluation. References: Management of the oral manifestations of senile purpura in an edentulous patient: a case report. (http://www.ncbi.nlm.nih.gov/pubmed/21592165)

An 89-Year-Old Woman Comes to the Physician Complaining of an Episodic