This episode of pain and ecchymotic pigmentation is far more intense than those he's had in the past. Does the patient's history offer clues to etiology?
A 32-year-old man with a history of systemic lupus presents to the emergency department with recurrent bilateral ear pain and discoloration. He denies fever, trauma or any recent piercing. Prior episodes have been milder and self-resolving so he never sought medical care, but this time it is much worse and has been going on for 4 days. He denies any other symptoms or any other prior medical problems.
On physical examination, vital signs are normal except for blood pressure of 168/99 mm Hg. He is afebrile. Head and neck exam is essentially normal except for the ears (Figure), which both appear slightly erythematous with an ecchymotic band through the pinnae. There are no swollen nodes. Lungs are clear and heart sounds are normal. The abdomen is benign. Extremities are without edema and the skin is otherwise clear.
Laboratory findings include metabolic panel within normal limits but the complete blood cell (CBC) count shows mild pancytopenia and sedimentation rate is elevated at 60 mm/h.
♦ What question should you ask him? (Hint: think social history)
♦ What other testing might be helpful?
♦ What is your diagnosis?
♦ What treatment course would you recommend?