LAUSR

Herein we describe the case of a 73-year-old man with Waldenstrom macroglobulinemia (WM) treated with therapeutic plasma exchange (TPE) for hyperviscosity who developed Rumpel-Leede (RL) sign after placement of a blood pressure (BP) cuff (see figure). The patient had a history of myocardial infarction for which he was being treated with both aspirin and prasugrel. Additionally, the patient had a normal platelet (PLT) count, was normotensive, had no history of diabetes mellitus, and had no known connective tissue disorders. After inflation of a BP cuff in preparation for TPE, the patient developed diffuse petechiae and scattered purpura distal to the site of cuff inflation. The patient had no previous history of easy bruising or PLT-type bleeding, and the petechiae and purpura resolved within 1 week. Acute dermis capillary rupture (RL sign) involves the development of petechiae after sudden increases in venous pressure after constriction such as occurs with a tourniquet or BP cuff. The phenomenon is associated with thrombocytopenia, PLT dysfunction, and capillary fragility. The condition has been described in patients with a wide variety of predisposing conditions including diabetes mellitus, Ehlers-Danlos syndrome, and hypertension. We surmise that aspirin and prasugrel’s anti-PLT activity may have contributed to the development of RL sign in this patient; however, contribution from WM-associated hyperviscosity could not be entirely excluded.