Leukocytoclastic vasculitis in the background of rheumatoid disease in a Native American in rural Oklahoma

Rural health care is often found to have underlying pathologic conditions that have been unattended to for years in some cases. In this case, a Native American/American Indian (NA/AI) patient from rural Northeast Oklahoma had years of troublesome joint pains until he was found to have anti-CCP (anti- cyclic citrullinated peptide) antibody positive rheumatoid disease (RD) with elevated inflammatory markers. This patient subsequently developed a bilateral lower extremity rash ranging from 1mm-4mm of palpable purpura, which was biopsied on two occasions four months apart. This palpable purpura/petechial rash started on feet and ankles, progressing up to mid calf bilaterally and was nonconfluent. He had no associated pain or pruritus with the rash. First biopsy results showed “superficial and deep perivascular interstitial dermatitis with vascular damage” consistent with leukocytoclastic vasculitis (LCV) Second biopsy result was forwarded to an outside pathology group for immunofluorescence, which showed perivascular IgG, complement C3 and fibrinogen deposits again favoring LCV. Small vessel vasculitis can be related to autoimmune origins including RA. It needs due recognition and attention in a timely fashion. Treatment can be very gratifying. There is an increasingly unmet need of Rheumatologists, more so, in rural areas of the country.