We herein report a 79-year-old man who developed anaphylactoid purpura after thoracic endovascular aortic repair, which he underwent for a distal aortic arch aneurysm of saccular type. On the third postoperative day he had purpura over his lower legs and abdomen accompanied by intermittent fever. His serum C-reactive protein concentration reached a maximum of 12 mg/dl, and remained at around 4 mg/dl thereafter. A dermatologist diagnosed anaphylactoid purpura ; this gradually improved with topical steroid and the nature and dosage of the oral medication. We suspected the presence of malignancy ; however, appropriate investigations failed to identify a cause for the purpura. During 6 months of outpatient follow up he has been free of recurrence. Anaphylactoid purpura occurs most frequently in childhood, often after an upper respiratory tract infection, whereas this condition is rare in adults. Triggers for anaphylactoid purpura include surgery, infection, certain medications, chronic lung, liver, or renal failure, and malignancy. We believe that the stress of undergoing thoracic endovascular aortic repair was the trigger in this case. Anaphylactoid purpura may be complicated by arthritis, gastrointestinal involvement and renal manifestations. There were no such complications in this case.

A 61-year-old man was referred to our hospital due to a 3-month history of fever of unknown origin, and with right knee and ankle joint pains. At another hospital, extensive investigations had produced negative results, including multiple sterile cultures of blood and joint fluids, and negative autoantibodies. His serum uric acid level was not elevated. However, after admission to our hospital, we performed right knee arthrocentesis, which revealed uric acid crystals. These findings, combined with the results of imaging tests, which showed joint degeneration, led to a diagnosis of advanced erosive gout. After receiving a therapeutic non-steroidal anti-inflammatory drug and a maintenance dose of colchicine for prophylaxis against recurrence, the patient's symptoms subsided and did not return. Advanced erosive gout should be considered a possible cause of fever of unknown origin and diagnostic arthrocentesis should be performed in patients with unexplained arthritis.
Ankle Joint ; Arthritis ; Autoantibodies ; Colchicine ; Diagnosis ; Fever of Unknown Origin* ; Gout* ; Humans ; Joints ; Knee ; Middle Aged ; Recurrence ; Uric Acid

Objective: Poor R wave progression in right precordial leads is a relatively common electrocardiogram (ECG) finding that indicates possible prior anterior myocardial infarction (MI); however, it is observed frequently in apparently normal individuals. In contrast, reversed R wave progression (RRWP) may be more specific to cardiac disorders; however, the significance of RRWP in daily clinical practice is unknown. The purpose of this study was to clarify the significance of RRWP in clinical practice.Materials and Methods: We analyzed consecutive ECGs obtained from 12,139 patients aged ≥20 years at Mito Kyodo General Hospital in Ibaraki between November 2009 and August 2012. Our setting is a secondary emergency hospital in the community, and the study participants were inpatients or patients who visited the general or emergency outpatient departments. RRWP was defined as RV2 < RV1, RV3 < RV2, or RV4 < RV3. Regarding ECGs considered to show RRWP, we confirmed the presence or absence of an abnormal Q wave and whether ultrasound cardiography, contrast-enhanced computed tomography, coronary angiography, and/or left ventriculography were performed to obtain detailed information.Results: RRWP was identified in 34 patients (0.3%). Among these patients, 29 (85%) had undergone cardiac evaluation. The final diagnosis was previous anterior MI in 12 patients (41%) and ischemic heart disease (IHD) without MI in 5 patients (17%). All 17 patients with IHD had left anterior descending (LAD) artery stenosis. The other patients were diagnosed with dilated (two patients, 7%) and hypertrophic (one patient, 3%) cardiomyopathy, left ventricular hypertrophy (one patient, 3%), or pulmonary embolism (one patient, 3%). Only seven patients (24%) were normal.Conclusions: RRWP is rare in daily clinical practice; however, it is a highly indicative marker for cardiac disease, particularly IHD with LAD artery stenosis.