A 54-year-old gentleman who drank half a bottle of vodka daily for over 20 years presents with severe epigastric pain and a bilateral lower limb violaceous skin rash for 1 week. This is associated with fever and confusion.
•Temperature 38.2°C, pulse 120 bpm, BP 120/78mmHg, SaO2 95% on RA.
•Hydration on the dry side.
•Examination of the hands reveals no clubbing, palmar erythema and a hepatic flap.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a central tenderness, but no guarding/rebound tenderness.
•GCS 14/15 with confused speech and disorientation; otherwise there is no focal neurological deficit detected.
•Mild lower limb oedema is noted.
Figure 7.1 is a clinical photo of his lower limb rash.
A violaceous, slightly indurated, tender maculopapular rash has developed over his lower limbs.
–WBC 33 x 109/L;
–platelets 255 x 109/L.
•Amylase 1058 IU/L.
•Liver and renal function tests are normal.
•International Normalised Ratio is normal.
What are the potential causes for the skin lesions?