An unusual case of small vessel vasculitic ulcer associated with chronic inactive hepatitis b infection

PAN is a systemic disease which can have different skin manifestations including tender erythematous nodules, purpura, livedo reticularis, ulcers, and bullous or vesicular eruption. Here we present a case of rapidly progressing skin ulcers in a 67 year old male with a past medical history significant for seizure disorder, hypothyroidism, and chronic inactive hepatitis B. He was admitted for right lower extremity cellulitis with necrotic ulceration. Surgical excisional debridement was performed at the bedside on the left leg. Post-debridement the patient started having fever spikes and was treated with intravenous ciprofloxacin. Cultures revealed growth of pseudomonas aeruginosa and beta hemolytic streptococcus group B from the right lower extremity. Venous studies revealed an old deep vein thrombosis in bilateral common femoral, femoral and popliteal veins. Rheumatological work up revealed elevated ESR levels of 104 mm/hr, high sensitivity CRP of >160.0 and positive ANA titers of 1:80 with speckled pattern. The probability of PAN became high in our differential given his history of chronic hepatitis B infection. A skin biopsy of the left ankle revealed acute and chronic inflammation along with perivascular neutrophilic inflammation, suggestive of leukocytoclastic vasculitis confirming the diagnosis of PAN. The patient was then started on prophylactic Tenofovir and steroids which led to significant improvement as evidenced by declining inflammatory parameters, rapidly healing ulcers and no further fever spikes. Antibiotics were slowly tapered off and the patient was discharged home on oral prednisone and Tenofovir. Hepatitis B infection regardless of activity status should prompt physicians to include PAN in the differential diagnosis of patients presenting with similar skin lesions along with signs of systemic inflammation. Timely initiation of steroids remains the gold standard therapy after prophylactic antiviral therapy is initiated in patient with chronic inactive status.