Periorbital purpura in a 66-year-old man: clue for spot diagnosis

A 66-year-old Hispanic male was presented to our primary care clinic for a workup of hypercalcemia. He had hoarseness of voice, difficulty in breathing and inability to swallow his saliva. In addition, he had multiple medical problems, including hypertension, congestive heart failure, chronic atrial fibrillation, Parkinson disease and benign prostatic hyperplasia. The patient was on warfarin. He had no history of recent trauma. The physical examination revealed an irregular heart rate (atrial fibrillation), significant macroglossia, respiratory stridor, drooling and periorbital purpura; (Figures 1 and 2). Laboratory testing showed a minimal elevation of partial thromboplastin time at 43.4 (normal range 15–37) s, and an international normalized ratio of 2.4 (normal range 0.9–1.10) and a normal platelet count. A lingual biopsy was performed at the time of a tracheostomy. Histopathological staining …