A 60-year-old man presents to the clinic with complaints of a recurring rash. He states that for the

A 60-year-old man presents to the clinic with complaints of
a recurring rash. He states that for the past 2–3 months, he has had several
episodes of a painless, nonpruritic rash over his distal lower extremities. The
lesions are described as purple and raised. His medical history is remarkable
for hepatitis C—with no history of cirrhosis—and peripheral neuropathy. The
patient has recently been treated for otitis media with amoxicillin. He has
taken no other medications. Physical examination is notable only for multiple
reddish-purple papules over the distal lower extremities (palpable
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A 60-year-old man presents to the clinic with complaints of
a recurring rash. He states that for the past 2–3 months, he has had several
episodes of a painless, nonpruritic rash over his distal lower extremities. The
lesions are described as purple and raised. His medical history is remarkable
for hepatitis C—with no history of cirrhosis—and peripheral neuropathy. The
patient has recently been treated for otitis media with amoxicillin. He has
taken no other medications. Physical examination is notable only for multiple
reddish-purple papules over the distal lower extremities (palpable purpura).
The underlying skin is hyperpigmented. Biopsy reveals neutrophils, neutrophilic
debris, and amorphous protein deposits involving the small blood vessels,
consistent with fibrinoid necrosis.

Questions

A. What is the likely dermatologic diagnosis? What are some
possible precipitants of that disease in this patient?

B. What is the underlying pathogenetic mechanism by which the
lesions are formed?

C. What histologic characteristics are responsible for the
appearance of the lesions as papular and purpuric?

D. What additional symptoms should this patient be asked
about? Should any laboratory tests be ordered?

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