Six weeks before the current evalua

Six weeks before the current evaluation, the patient saw a dermatologist. He reported having an influenza-like illness with cough and congestion for 4 weeks. Mildly pruritic wheals were scattered on the abdomen and arms; a faint morbilliform rash was present on the arms, trunk, back, and thighs; there was palpable purpura on both shins; and there was scleral injection (greater in the right eye than in the left eye). A biopsy specimen of a skin lesion on the right calf was obtained; pathological examination revealed findings consistent with leukocytoclastic vasculitis. Cetirizine, hydroxyzine, and topical triamcinolone were prescribed.Five weeks before the current evaluation, the patient went to a third hospital because of right lower abdominal pain. He rated the pain at 6 to 7 on a scale of 1 to 10, with 10 indicating the most severe pain; it was neither precipitated nor relieved by eating, and he had no nausea, vomiting, diarrhea, or hematochezia. Serum levels of electrolytes, alkaline phosphatase, amylase, and lipase were normal, as were tests of renal and liver function; other test results are shown in Table 1. Urinalysis was normal, and a blood culture was sterile. Computed tomography reportedly ruled out appendicitis. The symptoms improved with hydration, and the patient was discharged the next day.The following day, the patient returned to the dermatologist. The cutaneous examination was unchanged. A tapering 12-day course of prednisone (starting dose, 60 mg per day) and azithromycin (5-day course) were prescribed. At a follow-up appointment 16 days later, the patient reported persistent fatigue. On examination, persistent purpura was present on the legs; the truncal rash had decreased. The use of triamcinolone cream was continued. Six days later, he saw an ophthalmologist because of red eyes. Examination reportedly showed diffuse bilateral scleral injection, worse in the right eye, chemosis, and decreased tears. Glucocorticoid ophthalmic drops and a lubricant ophthalmic solution were prescribed.