CASE

A 56-year-old man presented to the emergency department with a chief complaint of “rash” on both lower extremities (slightly worse on the left than on the right). The rash first appeared after he completed a round of golf on a warm, sunny day in Charleston, South Carolina, about 6 hours prior to presentation. The gradually developing rash was mildly pruritic. According to the patient, the left lower leg might be slightly swollen, but there was no pain. He reported no chest pain, shortness of breath, or exposure to poison ivy or poison oak. He had not taken any medications or applied any creams or lotions recently. None of his golf round was spent in high grass or weeds. He denied oliguria or dark urine.

Medical history was significant for generalized osteoarthritis and a right knee replacement approximately 3 years previously. He had not seen a physician in more than a year. There was no personal or family history of atopy.

Physical examination revealed a well-nourished, well-hydrated, white male in no acute distress. Pulse was 70 beats per minute and regular; respiration rate, 16 breaths per minute; BP, 118/78 mm Hg; temperature, 97.3°F; and SaO2, 100%. Head, eyes, ears, nose, and throat were unremarkable. Heart and lungs sounded normal. Findings from the abdominal examination were normal. Both legs showed significant diffuse nonpalpable petechiae extending from the knee to the ankle (Figure 1). The rash, which seemed slightly worse on the left leg than the right, stopped abruptly on a circumferential line at the sock line. Both legs demonstrated full range of motion without crepitus. No tenderness was present. A well-healed surgical scar was visible on the right knee. The remainder of the physical examination was unremarkable. A urine dipstick showed just a trace amount of protein; the results from a full urinalysis were completely normal.

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DISCUSSION

The patient had golfer's vasculitis, a benign condition seen primarily in middle-aged persons after they have played a round of golf in hot weather. The condition is also seen in walkers and joggers.

Ruling out other diagnoses in contrast to this patient's eruption, contact dermatitis is rarely exclusively macular and often includes a local vesicular reaction. Pointed questioning uncovered no history of medication use, including OTC medications. No history of fever or other constitutional symptoms associated with leukocytoclastic vasculitis were reported. Because petechiae and purpura in general are symptomatic of leukocytoclastic vasculitis, Wegener's granulomatosis, rheumatoid arthritis, lupus, and other autoimmune disorders, golfer's vasculitis occasionally prompts a vigorous evaluation by a dermatologist or rheumatologist and results in needless expense and angst. The urinary findings ruled out an acute hemolytic process and renal dysfunction.

A self-limited disorder, golfer's vasculitis typically disappears spontaneously in 24 to 48 hours but frequently recurs with additional hot-weather activity. There is no known cure or preventive method other than avoidance of vigorous activity in hot weather. Application of cool compresses to the lower legs may reduce swelling and the mild pruritus that is sometimes associated with the condition. JAAPA

Arnold Metz is an assistant professor in the PA program at the Medical University of South Carolina in Charleston. The author has indicated no relationships to disclose relating to the content of this article.

Acknowledgement: The author wishes to acknowledge the contribution of Daniel E. Lewis, MD, in the preparation of this article.

Joe R. Monroe, PA-C, MPAS, department editor