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85&#41;&#59; he had smoked for 30 years &#40;90 packs&#47;year&#41; and did not consume alcohol on a regular basis&#46; He had been diagnosed with type 2 diabetes mellitus in 1975&#44; but showed no evidence of dyslipidemia&#46; He had a history of hypertension&#44; hyperuricemia&#44; New York Heart Association class III heart failure &#40;for which he had been hospitalized in June and August 2013 and March 2014&#41;&#44; lumbar spinal stenosis&#44; benign prostate hyperplasia&#44; hiatal hernia&#44; diverticulosis and stage 3 chronic kidney disease &#40;basal creatine level&#58; 1&#46;2&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; He had undergone surgery for lumbar spinal stenosis and for perianal fistulas&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was taking repaglinide 2<span class="elsevierStyleHsp" style=""></span>mg &#40;1-1-1&#41;&#44; insulin glargine &#40;23-0-0&#41;&#44; atorvastatin 10<span class="elsevierStyleHsp" style=""></span>mg &#40;0-0-1&#41;&#44; 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Seven days before his admission to the emergency department&#44; he had received cefuroxime to treat cystitis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ancillary studies included chest radiography&#44; which revealed interstitial edema and acute pulmonary edema&#44; and electrocardiogram&#44; which showed atrial fibrillation at 70<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#44; QRS 0&#46;12<span class="elsevierStyleHsp" style=""></span>s and right bundle branch block&#46; Laboratory test results included creatinine 3&#46;60<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; sodium 132<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#44; potassium 6&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L and pro-brain natriuretic peptide 5308<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There were no other relevant findings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis appeared to be acute pulmonary edema and worsening renal function with hyperkalemia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">During his hospital stay&#44; he required treatment with metoclopramide hydrochloride 10<span class="elsevierStyleHsp" style=""></span>mg&#44; morphine hydrochloride 2<span class="elsevierStyleHsp" style=""></span>mg&#44; pump infusion of glyceryl trinitrate 50<span class="elsevierStyleHsp" style=""></span>mg at 250&#8211;3<span class="elsevierStyleHsp" style=""></span>mL&#47;h&#44; furosemide 60<span class="elsevierStyleHsp" style=""></span>mg&#44; infusion of furosemide 80<span class="elsevierStyleHsp" style=""></span>mg in 50<span class="elsevierStyleHsp" style=""></span>cc saline solution at 0&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;h&#44; enema with calcium resonium 50<span class="elsevierStyleHsp" style=""></span>g in 200<span class="elsevierStyleHsp" style=""></span>mL of water&#44; insulin aspart 10<span class="elsevierStyleHsp" style=""></span>IU in 100<span class="elsevierStyleHsp" style=""></span>cc saline solution&#44; 5&#37; glycerol solution at 200<span class="elsevierStyleHsp" style=""></span>mL&#47;hour and oxygen delivered with continuous positive airway pressure &#40;CPAP&#41; and positive end-expiratory pressure &#40;PEEP&#41; of 4<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Throughout the patient&#39;s 10-h stay&#44; his vital signs were monitored every 10<span class="elsevierStyleHsp" style=""></span>min&#46; At one point&#44; lesions delimited by the blood pressure cuff were observed on his left arm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and we decided to study their progress&#46; Once the patient had been stabilized&#44; he was transferred to the referral hospital for nephrological evaluation and possible dialysis due to renal failure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">During the follow-up of the patient in the referral hospital&#44; the skin lesion spread to his other 3 limbs&#44; and a thorough study of the pathological and clinical features&#44; the determination of the presence of eosinophils&#44; and a biopsy led to the diagnosis of leukocytoclastic vasculitis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">This phenomenon suggests 2 feasible hypotheses&#46; The first is the possible development of ecchymosis due to malpractice in blood pressure measurement&#44; which the patient had undergone every 5<span class="elsevierStyleHsp" style=""></span>min for 10<span class="elsevierStyleHsp" style=""></span>h&#46; We have found no reports in the literature dealing expressly with secondary effects of the technique for taking blood pressure&#46; Thus&#44; the hypothesis that the ecchymosis we describe might be a result of this measurement could not be evaluated because of the lack of studies that confirm it&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding the second hypothesis&#44; we cannot assume that serial blood pressure readings were responsible for ecchymosis as an early sign of leukocytoclastic vasculitis without other studies that confirm the existence of this possibility&#46; However&#44; our experience suggests that venous stasis may have facilitated and accelerated the reactions mediated by the immune system&#44; which responded to the allergen&#44; in this case&#44; the antibiotic prescribed for cystitis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In addition to histopathological confirmation&#44; the diagnosis of this type of vasculitis requires complete analyses of blood and urine to rule out organ involvement&#46; This case&#44; which was caused by a drug reaction&#44; had an excellent prognosis&#46; However&#44; vasculitides associated with severe diseases have a more aggressive clinical progression&#44; with hemorrhagic lesions&#44; blistering and ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> The differential diagnosis should involve thrombocytopenia &#40;although generally&#44; in these cases&#44; the purpuric lesions are not palpable&#41;&#44; disseminated intravascular coagulation &#40;more or less extensive purpura&#44; which may or may not be palpable&#41;&#44; scurvy &#40;hemorrhagic follicular papules on lower extremities&#41; and other similar purpuric dermatoses &#40;purpuric maculae&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We propose the need for a study of possible secondary effects of arterial blood pressure measurement&#59; should it be found that there are really no such effects&#44; we wonder whether this procedure might be useful for other purposes&#44; such as the early detection of problems like vasculitis&#44; and all those presenting with purpura&#46; If these lesions had been considered a symptom of vasculitis&#44; we would have been able to provide early treatment and resolution of the condition&#44; sparing the patient from undergoing such exhaustive testing and saving on health costs&#46; Moreover&#44; although on this occasion&#44; the vasculitis was not severe&#44; had it been so&#44; we would have been able to treat the patient promptly to ensure a good prognosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Given that routine practice rules out ecchymosis as a secondary effect of blood pressure measurement and&#44; in view of the failure to find scientific evidence that confirms any such relationship&#44; we suggest that ecchymosis secondary to venous stasis could be considered a warning to alert to a possible diagnosis of vasculitis&#46; Being that vasculitis is an inflammatory process&#44; and assuming the inflammatory theory regarding the accumulation of different immune complexes due to edema and flush&#44; if the latter translates into a rise in pressure on the local level&#44; and this pressure increases with the measurement of the vital sign&#44; the consequence could be a rapid change in the clinical signs on the local level&#44; as was observed in the case we report here&#46; The measurement of the blood pressure every 10<span class="elsevierStyleHsp" style=""></span>min over a several hours&#44; starting soon after admission of the patient&#44; could even be proposed as a primary screening tool to confirm or refute the differential diagnosis of vasculitis when more thorough studies have supported it&#44; as it is not invasive and has no secondary effects&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of Interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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          "clase" => "keyword"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Description of appearance of ecchymosis on an arm&#44; simultaneously with a classical leukocytoclastic vasculitis&#44; the proposal of alternative utilities of measuring blood pressure&#44; and the study of side effects to that measure&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patient</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 80-year-old male came to ER with dyspnea&#44; heart failure&#44; predialysis renal failure with hyperkalemia and hemodynamic instability&#46; During his stay he developed a skin lesion that looks like palpable purpura&#44; from the lower limit of the blood pressure cuff to the distal area of the hand that not disappeared with vitropression&#44; and pruritus&#46; During admission the arm injury was extended to all members&#44; both upper and lower&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study concluded with diagnosis of leukocytoclastic vasculitis given the presence of eosinophils&#44; that which suggested probable drug etiology to an antibiotic that had been taken since seven days prior to admission to ER&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The need for serial monitoring of blood pressure&#44; and the duration of such monitoring in unstable patients considering the side effects of those techniques was questioned&#46; In addition&#44; the study of other utilities of measuring blood pressure&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de aparici&#243;n de una equimosis en brazo simult&#225;neamente con vasculitis de origen leucocitocl&#225;stica&#44; propuesta de usos alternativos a la toma de presi&#243;n arterial&#44; y el estudio de efectos secundarios a dicha medida&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Paciente</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Var&#243;n de 80 a&#241;os acude a urgencias con disnea&#44; insuficiencia card&#237;aca&#44; insuficiencia renal predi&#225;lisis con hiperpotasemia e inestabilidad hemodin&#225;mica&#46; Durante su estancia desarroll&#243; una lesi&#243;n cut&#225;nea con aspecto de p&#250;rpura palpable&#44; desde el l&#237;mite inferior del manguito de presi&#243;n arterial hasta la zona distal de la mano y que no desaparec&#237;a a la vitropresi&#243;n&#44; y prurito&#46; Durante su ingreso&#44; la lesi&#243;n del brazo se extendi&#243; a todos los miembros&#44; tanto superiores como inferiores&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El estudio de la lesi&#243;n concluy&#243; con diagn&#243;stico de vasculitis leucocitocl&#225;stica por presencia de eosin&#243;filos&#44; lo que sugiere probable etiolog&#237;a medicamentosa a la toma de antibi&#243;tico desde 7 d&#237;as antes de la entrada a urgencias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se plantea la necesidad de monitorizaci&#243;n seriada de la presi&#243;n arterial y la duraci&#243;n de dicha monitorizaci&#243;n en pacientes inestables frente a los efectos secundarios de esta t&#233;cnica&#46; Tambi&#233;n el estudio de otras utilidades de la toma de presi&#243;n arterial&#46;</p></span>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
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                          ]
                        ]
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            1 => array:3 [
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                          "etal" => false
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                            1 => "D&#46;S&#46; Wright"
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                          "etal" => false
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Case report
Vasculitis After Blood Pressure Monitoring
Vasculitis tras la monitorización de presión arterial
Olga Ventura-Ribesa, Francisco H. Machancosesb,
Corresponding author
herrerof@uji.es

Corresponding author.
, Jesús F. Rosel Remírezb
a Hospital de la Plana, Vila-real, Castellón, Spain
b Universitat Jaume I, Facultat de Ciències de la Salut, Castelló de la Plana, Castellón, Spain
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Image of the lesion beneath the mark of the blood pressure cuff&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Blood pressure monitoring is a commonly utilized technique&#44; and the possible secondary effects have been fully described in the intraoperative setting and in lesions produced by amputation&#46; Nevertheless&#44; there are no in-depth studies involving possible effects of serial arterial blood pressure measurements&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Nevertheless&#44; as the latter technique can be associated with certain risks&#44; a number of guidelines stress the need to change the cuff from one arm to another every 8<span class="elsevierStyleHsp" style=""></span>h&#46; In this respect&#44; the literature provides descriptions of traumatic lesions to the skin by incorrect cuff placement&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">1&#44;2</span></a> The pressure exerted by the cuff can result in bruises&#44; chafing&#44; ecchymosis and blistering&#46; It can also produce burns if solutions are administered via a catheter placed beneath the cuff&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3&#44;4</span></a> When tourniquets are employed during surgical procedures&#44; it is recommended that they be deflated every 30<span class="elsevierStyleHsp" style=""></span>min&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">5&#44;6</span></a> Thus&#44; a skin lesion that is delimited by the edge of the cuff raises doubts as to the diagnosis&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Leukocytoclastic vasculitis encompasses a heterogeneous group of disease processes characterized by inflammation and necrosis of vessel walls&#46; This inflammation is mediated by 3 immunological factors&#58; the deposition of circulating immune complexes&#44; the direct binding of antibodies to antigens present in vessel walls&#44; and leukocyte activation by antineutrophil cytoplasmic antibodies &#40;ANCA&#41; specifically targeting leukocyte antigens&#46; The size and shape of the immune complexes determine the type of vessel affected&#8212;depending on the organ involved and its size&#8212;and the clinical features of the disease&#46; The clinical signs vary because they depend on the territory irrigated by the vessel involved&#46; Thus&#44; the disease can be benign<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> or extremely severe&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Case Report</span><p id="par0020" class="elsevierStylePara elsevierViewall">An 80-year-old man was admitted to the emergency department&#44; to which he had been referred at 00&#58;11<span class="elsevierStyleHsp" style=""></span>h by the continuing care physician due to an increase in his usual dyspnea&#44; accompanied by anuria over the previous 24<span class="elsevierStyleHsp" style=""></span>h&#46; He presented with a poor general appearance&#44; shallow breathing&#44; pallor and blue lips&#44; but was normally hydrated&#44; conscious and alert&#46; His vital signs on admission were&#58; arterial blood pressure&#44; 143&#47;47<span class="elsevierStyleHsp" style=""></span>mmhg&#59; heart rate&#44; 60<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#59; body temperature&#44; 36&#46;2<span class="elsevierStyleHsp" style=""></span>&#176;C&#59; oxygen saturation&#44; 52&#37;&#59; and Glasgow Coma Scale score&#44; 15&#46; His heart sounds were arrhythmic without murmurs and&#44; in lung&#44; vesicular and sibilant sounds were absent&#46; His abdomen was distended&#44; soft and depressible&#44; with no evidence of peritonism&#44; masses or organ enlargement&#46; He had edemas in his extremities and pitting edema up to the knees&#44; with palpable pulses&#46; We found no focal neurological deficits&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patient had no known drug allergies and was completely independent in his activities of daily living &#40;Barthel index&#44; 85&#41;&#59; he had smoked for 30 years &#40;90 packs&#47;year&#41; and did not consume alcohol on a regular basis&#46; He had been diagnosed with type 2 diabetes mellitus in 1975&#44; but showed no evidence of dyslipidemia&#46; He had a history of hypertension&#44; hyperuricemia&#44; New York Heart Association class III heart failure &#40;for which he had been hospitalized in June and August 2013 and March 2014&#41;&#44; lumbar spinal stenosis&#44; benign prostate hyperplasia&#44; hiatal hernia&#44; diverticulosis and stage 3 chronic kidney disease &#40;basal creatine level&#58; 1&#46;2&#8211;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; He had undergone surgery for lumbar spinal stenosis and for perianal fistulas&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was taking repaglinide 2<span class="elsevierStyleHsp" style=""></span>mg &#40;1-1-1&#41;&#44; insulin glargine &#40;23-0-0&#41;&#44; atorvastatin 10<span class="elsevierStyleHsp" style=""></span>mg &#40;0-0-1&#41;&#44; furosemide 40<span class="elsevierStyleHsp" style=""></span>mg &#40;2-1-0&#41;&#44; doxazosin 8<span class="elsevierStyleHsp" style=""></span>mg &#40;1-0-0&#41;&#44; amlodipine 10<span class="elsevierStyleHsp" style=""></span>mg &#40;1-1-0&#41;&#44; paracetamol &#40;1-1-1&#41;&#44; omeprazole 20<span class="elsevierStyleHsp" style=""></span>mg &#40;0-0-1&#41;&#44; lormetazepam 1<span class="elsevierStyleHsp" style=""></span>mg &#40;0-0-1&#41;&#44; acetylsalicylic acid 100<span class="elsevierStyleHsp" style=""></span>mg &#40;0-1-0&#41;&#44; allopurinol 100<span class="elsevierStyleHsp" style=""></span>mg &#40;0-1-0&#41;&#44; bisoprolol 2&#46;5<span class="elsevierStyleHsp" style=""></span>mg &#40;1-0-0&#41;&#44; moxonidine 0&#46;4<span class="elsevierStyleHsp" style=""></span>mg &#40;1-0-0&#41;&#44; iron &#40;1-0-0&#41;&#44; losartan 100<span class="elsevierStyleHsp" style=""></span>mg &#40;1-0-0&#41; and calcium 500<span class="elsevierStyleHsp" style=""></span>mg &#40;1-0-0&#41;&#46; Seven days before his admission to the emergency department&#44; he had received cefuroxime to treat cystitis&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">Ancillary studies included chest radiography&#44; which revealed interstitial edema and acute pulmonary edema&#44; and electrocardiogram&#44; which showed atrial fibrillation at 70<span class="elsevierStyleHsp" style=""></span>beats&#47;min&#44; QRS 0&#46;12<span class="elsevierStyleHsp" style=""></span>s and right bundle branch block&#46; Laboratory test results included creatinine 3&#46;60<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; sodium 132<span class="elsevierStyleHsp" style=""></span>mmol&#47;L&#44; potassium 6&#46;6<span class="elsevierStyleHsp" style=""></span>mmol&#47;L and pro-brain natriuretic peptide 5308<span class="elsevierStyleHsp" style=""></span>pg&#47;mL&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">There were no other relevant findings&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The diagnosis appeared to be acute pulmonary edema and worsening renal function with hyperkalemia&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">During his hospital stay&#44; he required treatment with metoclopramide hydrochloride 10<span class="elsevierStyleHsp" style=""></span>mg&#44; morphine hydrochloride 2<span class="elsevierStyleHsp" style=""></span>mg&#44; pump infusion of glyceryl trinitrate 50<span class="elsevierStyleHsp" style=""></span>mg at 250&#8211;3<span class="elsevierStyleHsp" style=""></span>mL&#47;h&#44; furosemide 60<span class="elsevierStyleHsp" style=""></span>mg&#44; infusion of furosemide 80<span class="elsevierStyleHsp" style=""></span>mg in 50<span class="elsevierStyleHsp" style=""></span>cc saline solution at 0&#46;2<span class="elsevierStyleHsp" style=""></span>mL&#47;h&#44; enema with calcium resonium 50<span class="elsevierStyleHsp" style=""></span>g in 200<span class="elsevierStyleHsp" style=""></span>mL of water&#44; insulin aspart 10<span class="elsevierStyleHsp" style=""></span>IU in 100<span class="elsevierStyleHsp" style=""></span>cc saline solution&#44; 5&#37; glycerol solution at 200<span class="elsevierStyleHsp" style=""></span>mL&#47;hour and oxygen delivered with continuous positive airway pressure &#40;CPAP&#41; and positive end-expiratory pressure &#40;PEEP&#41; of 4<span class="elsevierStyleHsp" style=""></span>cm H<span class="elsevierStyleInf">2</span>O&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Throughout the patient&#39;s 10-h stay&#44; his vital signs were monitored every 10<span class="elsevierStyleHsp" style=""></span>min&#46; At one point&#44; lesions delimited by the blood pressure cuff were observed on his left arm &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and we decided to study their progress&#46; Once the patient had been stabilized&#44; he was transferred to the referral hospital for nephrological evaluation and possible dialysis due to renal failure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">During the follow-up of the patient in the referral hospital&#44; the skin lesion spread to his other 3 limbs&#44; and a thorough study of the pathological and clinical features&#44; the determination of the presence of eosinophils&#44; and a biopsy led to the diagnosis of leukocytoclastic vasculitis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Discussion</span><p id="par0065" class="elsevierStylePara elsevierViewall">This phenomenon suggests 2 feasible hypotheses&#46; The first is the possible development of ecchymosis due to malpractice in blood pressure measurement&#44; which the patient had undergone every 5<span class="elsevierStyleHsp" style=""></span>min for 10<span class="elsevierStyleHsp" style=""></span>h&#46; We have found no reports in the literature dealing expressly with secondary effects of the technique for taking blood pressure&#46; Thus&#44; the hypothesis that the ecchymosis we describe might be a result of this measurement could not be evaluated because of the lack of studies that confirm it&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Regarding the second hypothesis&#44; we cannot assume that serial blood pressure readings were responsible for ecchymosis as an early sign of leukocytoclastic vasculitis without other studies that confirm the existence of this possibility&#46; However&#44; our experience suggests that venous stasis may have facilitated and accelerated the reactions mediated by the immune system&#44; which responded to the allergen&#44; in this case&#44; the antibiotic prescribed for cystitis&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In addition to histopathological confirmation&#44; the diagnosis of this type of vasculitis requires complete analyses of blood and urine to rule out organ involvement&#46; This case&#44; which was caused by a drug reaction&#44; had an excellent prognosis&#46; However&#44; vasculitides associated with severe diseases have a more aggressive clinical progression&#44; with hemorrhagic lesions&#44; blistering and ulceration&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a> The differential diagnosis should involve thrombocytopenia &#40;although generally&#44; in these cases&#44; the purpuric lesions are not palpable&#41;&#44; disseminated intravascular coagulation &#40;more or less extensive purpura&#44; which may or may not be palpable&#41;&#44; scurvy &#40;hemorrhagic follicular papules on lower extremities&#41; and other similar purpuric dermatoses &#40;purpuric maculae&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">9</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">We propose the need for a study of possible secondary effects of arterial blood pressure measurement&#59; should it be found that there are really no such effects&#44; we wonder whether this procedure might be useful for other purposes&#44; such as the early detection of problems like vasculitis&#44; and all those presenting with purpura&#46; If these lesions had been considered a symptom of vasculitis&#44; we would have been able to provide early treatment and resolution of the condition&#44; sparing the patient from undergoing such exhaustive testing and saving on health costs&#46; Moreover&#44; although on this occasion&#44; the vasculitis was not severe&#44; had it been so&#44; we would have been able to treat the patient promptly to ensure a good prognosis&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Conclusion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Given that routine practice rules out ecchymosis as a secondary effect of blood pressure measurement and&#44; in view of the failure to find scientific evidence that confirms any such relationship&#44; we suggest that ecchymosis secondary to venous stasis could be considered a warning to alert to a possible diagnosis of vasculitis&#46; Being that vasculitis is an inflammatory process&#44; and assuming the inflammatory theory regarding the accumulation of different immune complexes due to edema and flush&#44; if the latter translates into a rise in pressure on the local level&#44; and this pressure increases with the measurement of the vital sign&#44; the consequence could be a rapid change in the clinical signs on the local level&#44; as was observed in the case we report here&#46; The measurement of the blood pressure every 10<span class="elsevierStyleHsp" style=""></span>min over a several hours&#44; starting soon after admission of the patient&#44; could even be proposed as a primary screening tool to confirm or refute the differential diagnosis of vasculitis when more thorough studies have supported it&#44; as it is not invasive and has no secondary effects&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethical Disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Protection of human and animal subjects</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Confidentiality of data</span><p id="par0095" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Right to privacy and informed consent</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of Interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare they have no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Description of appearance of ecchymosis on an arm&#44; simultaneously with a classical leukocytoclastic vasculitis&#44; the proposal of alternative utilities of measuring blood pressure&#44; and the study of side effects to that measure&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patient</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Case 80-year-old male came to ER with dyspnea&#44; heart failure&#44; predialysis renal failure with hyperkalemia and hemodynamic instability&#46; During his stay he developed a skin lesion that looks like palpable purpura&#44; from the lower limit of the blood pressure cuff to the distal area of the hand that not disappeared with vitropression&#44; and pruritus&#46; During admission the arm injury was extended to all members&#44; both upper and lower&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The study concluded with diagnosis of leukocytoclastic vasculitis given the presence of eosinophils&#44; that which suggested probable drug etiology to an antibiotic that had been taken since seven days prior to admission to ER&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Discussion</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The need for serial monitoring of blood pressure&#44; and the duration of such monitoring in unstable patients considering the side effects of those techniques was questioned&#46; In addition&#44; the study of other utilities of measuring blood pressure&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Fundamento</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Descripci&#243;n de aparici&#243;n de una equimosis en brazo simult&#225;neamente con vasculitis de origen leucocitocl&#225;stica&#44; propuesta de usos alternativos a la toma de presi&#243;n arterial&#44; y el estudio de efectos secundarios a dicha medida&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Paciente</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Var&#243;n de 80 a&#241;os acude a urgencias con disnea&#44; insuficiencia card&#237;aca&#44; insuficiencia renal predi&#225;lisis con hiperpotasemia e inestabilidad hemodin&#225;mica&#46; Durante su estancia desarroll&#243; una lesi&#243;n cut&#225;nea con aspecto de p&#250;rpura palpable&#44; desde el l&#237;mite inferior del manguito de presi&#243;n arterial hasta la zona distal de la mano y que no desaparec&#237;a a la vitropresi&#243;n&#44; y prurito&#46; Durante su ingreso&#44; la lesi&#243;n del brazo se extendi&#243; a todos los miembros&#44; tanto superiores como inferiores&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">El estudio de la lesi&#243;n concluy&#243; con diagn&#243;stico de vasculitis leucocitocl&#225;stica por presencia de eosin&#243;filos&#44; lo que sugiere probable etiolog&#237;a medicamentosa a la toma de antibi&#243;tico desde 7 d&#237;as antes de la entrada a urgencias&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discusi&#243;n</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Se plantea la necesidad de monitorizaci&#243;n seriada de la presi&#243;n arterial y la duraci&#243;n de dicha monitorizaci&#243;n en pacientes inestables frente a los efectos secundarios de esta t&#233;cnica&#46; Tambi&#233;n el estudio de otras utilidades de la toma de presi&#243;n arterial&#46;</p></span>"
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                  "comentario" => "&#91;Internet&#93; available at&#58; <span class="elsevierStyleInterRef" id="intr0010" href="http://www.seg-social.es/ism/gsanitaria_es/ilustr_capitulo7/cap7_2_hemorragias.htm">http&#58;&#47;&#47;www&#46;seg-social&#46;es&#47;ism&#47;gsanitaria&#95;es&#47;ilustr&#95;capitulo7&#47;cap7&#95;2&#95;hemorragias&#46;htm</span> &#91;accessed 10&#46;10&#46;14&#93;"
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Idiomas
Reumatología Clínica (English Edition)
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