Purpuric rash on the lower legs

A woman in her late 50s presented with reduced mobility and a 16 month history of progressive leg swelling, lethargy, myalgia, weight loss, and bleeding gums. She had a history of fibromyalgia and hypothyroidism and had been given a diagnosis of venous insufficiency by her general practitioner. She took levothyroxine, gabapentin, carbamazepine, and co-codamol regularly and used emollients on her lower legs. She neither smoked nor drank alcohol. She reported consuming a limited diet of fish and bread for around 20 years. Her cardiovascular, respiratory, and abdominal examinations were all normal, and no lymphadenopathy was detected. Cutaneous examination showed bilateral, tender, pitting oedema with induration on the lower legs and widespread petechiae and purpura (fig 1). There were areas of bruising on the patient’s arms and legs and nail bed haemorrhages on her fingers. Several …