I did not understand the meaning of " Allergy related to temperature changes". The skin rash is mono or bilateral? In that foot an important edema is present: it is mono or bilateral?

Dr.Antonio, the skin rash is bilateral. And I mean with Allergy related to temperature changes, that high humidity induce shortness of breath.

And the other foot is the same with regard to the shape, but with varying degree of rash.

The word "rash" is for a temporary aspect that appears and disappears in a short time. On the contrary, this is not a rash. If in your patient the skin lesions are stable a kind of relativo with edema must be considered

Yeah Dr.Antonio, the skin lesions are stable. Any idea what could be the reasonable diagnosis? Any additional info.do you need?

Dear dr. Mostafa

I recommend taking biopsy from the skin lesion and take dermatologist opinion as well.

Dr.Khadeeja, do you suspect anything?

Skin lesions could be dystrophic lesions. So, the causes of edema might be investigated

Dr.Antonio, may you shed more light into this " dystrophic lesions "? And what could be the cause?

Dear Mostafa, dystrophic lesions of the skin, are various alteration caused by chronic defects of circulation like edema, vasculitis, chronic venous insuficiency and others). Because in your patient there is not present a "rash" but a chronic edema and a stable lesion of skin I think that your diagnostic effort might be directed on the circulatory problems.

. Chronic venous insufficiency. Circulation. 2014 Jul 22;130(4):333-46. doi: 10.1161/CIRCULATIONAHA.113.006898.

Dear dr. Mostafa,

For diagnosis, a detailed history of the lesion and its systemic association is needed. The lesions could be a type of small vessel vasculitis, rash of hypercoagubility state, embolic rashes (given the history of AF) or circulatory insufficiency. These can be differentiated by taking biopsy. But it could be a dermatological dyspigmentation problem, so it is worth to take dermatological consultation as well.

So Dr.Antonio, and Dr.Khadeeja, may I know ALL the possible diagnosis(So I can do the necessary tests to eliminate and reach the correct diagnosis? Because I'd like to make taking biopsy is my last resort due to being invasive.

Couldn't be due to any of the current medications taken? Like this case?

Article Palpable maculopapular rash with elevated ESR: What is your diagnosis?

May a good differential diagnosis between chron decompensated heart failure with dystrofic skin changes and ,maybe,chronic pelvis venous thrombosis with particular cutaneous signes.Use venous scan or flebography

Dr. Koco Cakalaroski what made you think it is chronic pelvis venous thrombosis ?

Dear dr. Mostafa

as I mentioned before, it could be type of small vessel vasculitis ( i.e. hypersensitivity vasculitis) which produces a maculopapular or purpuric rash usually in dependent area of body and is usually symmetrical. Investigations would be inconclusive and often normal. Definit diagnosis is histopathological examination by taking biopsy.

unfortunately, the rash in the picture is not obvious weather is maculopapular, purpuric or hyper-hypo pigmented rash. If it is a hypo-hyper pigmented rash, is usually a dermatological problem (Dyschromatosis Symmetrica stasis dermatitis, schamberg’s disease, ....). If not, it could be small vessel vasculitis, rash of hypercoagubility (antiphospholipid antibody syndrome) or an embolic rash.

Jazak allah khair Dr.Khadeeja

You are welcome dr. Mostafa, I hope my answers would help you.

I'm not an MD, but my advice would be to eliminate all the medications since the images shown could be side effects (per their package inserts) and they are targeted at the woman's symptoms, not the root causes. I would address the underlying causes of the woman's atrial fibrillation and hemorrhoids through diet (organic, eliminate inflammatory foods and those that impair tight junction integrity, such as gluten), exercise, and supplements chosen after running the appropriate blood work. Magnesium is most likely needed and would address both the fibrillation and hemorrhoids. Gut dysbiosis likely plays a major role since she's experiencing temperature-related allergies and that means the immune system is impaired/overreacting. I would consider consulting with a functional medicine doctor. If symptoms persist after eliminating meds and improving gut function, then environmental exposure causes should be found and addressed. Antiphospholipid antibody syndrome was mentioned in another comment, and that is related to hyperimmunization with tetanus vaccine.

Thank you Bernadette!

It turns out that this is primary vasculitis, so any idea what will be the likely prognosis if no treatment is initiated ? Because Immunosuppressants, and Corticosteroids do have a bad profile with regard to side effects.

Please can you specify which type of vasculitis it is, as histopathology should specify it? Because the treatment and prognosis depend on subtype of vasculitis

No Skin Biopsy was taken. The Physician said it is primary vasculitis, and want to initiate Azathioprine, and I wonder if no treatment was initiated, what is the likely prognosis on the long run ?

Dear dr. Mostafa

Although I recommend histopathological examination again to diffentiate the subtypes but if you refuse to do it and it has been confirmed to be vasculitis, you should search for any systemic involvement by doing CXR, echocardiography, renal US and GUE, complement level and eye consultation and looking for any nervous system involvement. If it was accompanied by serious systemic features then steroid and immunosuppresive agents will be required. If not just low dose steroid may be enough.

Thanks Dr.Khadeeja, but What if no systemic features exist, what is the likely outcome on the long term if no treatment was initiated ?

Vasculitis is a serious disease and it can’t be left untreated. Prognosis of vasculitis depends on underlying cause of vasculitis (e.g underlying CTD or malignancy or infection ...) and presence of other organ system involvement. Even if you excluded underlying CTD or malignancy( that may not fulfill their criteria at time of presentation but may do so later on) and no any organ was involved, the outcome still is unpredictable: sometimes it may remit after effective treatment and elimination of inciting cause like cases of hypersensitivity vasculitis which have good prognosis, or it may relapse after few months or it may become a chronic cutaneous disease. Furthermore, you can not be sure that other systems will not be involved in long term if the patient was left untreated.