Psychogenic purpura
A 45-year-old woman presented with a history of recurrent painful bruise-like mark over the lower extremities for the preceding 2 years. The lesions used to appear abruptly and were heralded by tingling or burning sensation, followed by a few areas of reddish discoloration progressing to ecchymoses within a couple of days. Lesions occurred at intervals of 1-2 months. There was no itching and the lesions improved spontaneously within a week or two, imparting a bluish discoloration initially that gradually subsided without leaving any trace. There was no preceding or concomitant history of injury, of drug intake, undernutrition, external bleeding, arthralgia, respiratory infection, central nervous system, or gastrointestinal symptoms. No family history of similar illness was present. Examination revealed a few slightly tender, bluish-red, non-edematous, and ecchymotic patches of 2-5 cm in diameter over the thighs [] and other parts of legs. Mucosae were normal and systemic examination was noncontributory. The result of intradermal autoerythrocyte sensitization test (done by injecting half ml of the patient's own blood as source of red blood cells (RBCs) into her forearm) was negative. Complete blood cell count including platelet count, bleeding time, clotting time, prothrombin time, and antinuclear antibodies were carried out on several occasions but was noncontributory. The patient was subsequently referred for psychiatric evaluation.\nPsychiatric profile of the patient revealed that the patient was the youngest of four siblings from a poor socieo-economic background and since her childhood, she poorly expressed her feelings or emotions. At the time of presentation, she was excessively worried about her present cutaneous problem. In addition, she had low level of mood, tension-type headache, easy fatigability, poor concentration, hyper-acidity, and sleep disturbance.\nAlthough stressors did not precede every episode, she could recall that the first episode precipitated after 4 days of her elder son's accidental death and another one was preceded by conflict with her husband regarding his extramarital relationship. She had two previous episodes of depression (the first episode, 4 years back followed by the second one 3 years ago) without any cutaneous lesion. There was no family history of any psychiatric illness. Clinical interview and mental status examination revealed moderate depressive episode with somatic syndrome (according to ICD-10). Psychometric assessment by Wechsler Adult Intelligence Scale (WAIS), Rorschach test, and Minnesota Multiphasic Personality Inventory-2 (MMPI-2) revealed that she had borderline intelligence (Full Scale Intelligence Quotient = 72) with depression, excessive interpersonal rejection sensitivity, high level of anxiety, and hypochondriacal concern. Based on the clinical course and laboratory features, the diagnosis of psychogenic purpura was made and the patient was put on escitalopram 10 mg/day and clonazepam 1 mg/day. Clonazepam was subsequently tapered off and the patient was maintained on escitalopram 10 mg/day. No recurrence of the cutaneous lesions was seen during a follow-up period of 9 months before she was lost to follow-up.