At the clinic visit, physical examination was notable for scattered pink
dermal papules with a dusky red center bilateral dorsal and palmar
hands, as well as bilateral conjunctival erythema. (Figure 1).
Differential diagnosis included erythema multiforme, acute febrile
neutrophilic dermatosis, erythema elevatum diutinum and multicentric
reticulohistiocytosis. A punch biopsy was taken from the left index
finger.
Histological examination revealed a dense perivascular and interstitial
inflammatory infiltrate composed of lymphocytes, histiocytes, and
numerous neutrophils with surrounding papillary dermal edema. High power
views demonstrated scattered nuclear dust and fibrin within the walls of
the small blood vessels with extravasation of red blood cells in the
surrounding stroma (Figure 2). The patient’s histopathological findings
were most consistent with leukocytoclastic vasculitis (LCV). Upon
discussion with the patient’s oncologist, it became known that the
patient had received an MMR vaccine two weeks prior to the rash. The
patient followed up one week later with a more typical appearing rash
for LCV (Figure 3). The rash resolved with use of topical clobetasol
ointment and his eyes also cleared. The patient has continued to receive
lenalidomide without any recurrence of the rash.