A 60-year-old policeman complains about a painful burning sensation in his lower extremities for several months. Lower limb petechiae appeared one week ago.
History Chronic fatigue and aching joints for past several months Received blood transfusion after a gunshot injury at his arm, 35 years ago. Distal paraesthesia of both legs and painful burning in both feet that has radiated to lower and upper limbs Severe knee pain Appendix removal at the age of ten No allergies; doesn’t take any regular medications Examination Heart rate – 83/min Blood pressure – 114/72 mmHg Temperature – 37.8◦C Looks tired, no pallor Livedo reticularis Symmetrically distributed palpable purpura in the lower extremities Bilateral supramalleolar skin ulcers Mild hepatomegaly Superficial hypoesthesia Loss of joint position and vibration sense, evidence of sensory ataxia Tendon reflexes were absent at the ankles…
