Gallbladder vasculitis associated with cutaneous leucocytoclastic vasculitis

A 72-year-old woman presented with a 1-week history of a painful, purpuric, pruritic rash on her legs, buttocks and arms. Skin biopsy revealed histological features typical of leucocytoclastic vasculitis. She was admitted, her usual medications were withheld, and she was commenced on ibuprofen and loratadine. The patient had undergone a laparoscopic cholecystectomy 2 months prior to her rash appearing. She had been having upper abdominal pain for 2 years and, following a more severe acute episode, an abdominal ultrasound scan had revealed a solitary cholelithiasis. Histology of the gallbladder revealed acute fibrinoid vasculitis in two small arteries, on a background of chronic cholecystitis. A mild postoperative wound infection was treated with a short course of cephalexin and no other investigations were conducted. As an inpatient, the patient's rash improved, but she progressed to develop systemic vasculitis and acute renal failure. Renal biopsy showed focal necrotizing glomerulonephritis, consistent with vasculitis. She was subsequently commenced on cyclophosphamide 100 mg daily, prednisolone 50 mg daily and one prophylactic trimethoprim/sulphamethoxazole (160 mg/800 mg) tablet 3 days/week. Following discharge, the patient's cutaneous vasculitis eventually resolved and renal function gradually improved. Her prednisolone was gradually reduced to 7 mg daily and cyclophosphamide was weaned, then substituted with azathioprine 100 mg daily.