LAUSR

A 64-year-old man with a history of celiac disease (CD), congestive heart failure, and diabetes mellitus complicated by end-stage renal disease and peripheral neuropathy, was admitted to the hospital for nonhealing ulcerations of his hands with osteomyelitis from his peripheral arterial vascular disease. He reported that his CD was under good control with a strict gluten-free diet prior to admission. Physical exam revealed prominent petechiae on his bilateral palms and fingers (Fig 1). A biopsy was performed and demonstrated collections of neutrophils in the papillary dermis (Fig 2).