A 50-Year-Old Woman With an Incidental But Significant Skin Finding

A 50-year-old white woman presents with a chief complaint of cough and dyspnea despite oral antibiotic therapy for a presumed exacerbation of chronic obstructive pulmonary disease (COPD).

She reports moderate sputum production and occasional mild hemoptysis. She denies any recent contact with ill persons or recent travel. She additionally reports frequent and often heavy epistaxis. She denies having fevers, night sweats, or unintentional weight loss. She has not experienced any recent diarrhea, melena or hematochezia

In addition to a past medical history of seizures, seasonal allergies, hypertension,
impaired gastric motility, anxiety, depression, and gastroesophageal reflux disease, she
has a longstanding history of chronic obstructive pulmonary disease (COPD), which is normally well-controlled with inhaled fluticasone/salmeterol and albuterol

The patient's other home medications include ethosuximide, loratadine, verapamil, metoclopramide, promethazine, alprazolam, temazepam, duloxetine, esomeprazole, aminocaproic acid, ferrous sulfate, and a multivitamin

Her past surgical history includes a cholecystectomy, knee arthroscopy, and a partial hysterectomy for cervical carcinoma. The patient's family history does not contribute to this admission, but it is significant in the pathologic process .

The patient is a current smoker but denies the use of any illicit drugs.

The physical examination reveals a 50-year-old white woman in no acute distress. Her oral temperature is 99.4°F (37.4°C). Her pulse is 80 bpm and her blood pressure is 111/63 mm Hg. A pulse oximetry examination reveals a room air saturation of 97%. Examination of the lungs shows bilateral rhonchi and mild wheezing. Examination of the cardiovascular system is unremarkable, as is the abdominal examination. Examination of the skin is remarkable for the pathologic process revealed in the images seen in Figures 1-3. She is also noted to have multiple superficial nonbleeding vessels on the nasal septum.

A portable chest radiograph is obtained, which does not reveal any effusions or infiltrates. A complete blood cell (CBC) count shows an increased white blood cell (WBC) count of 15.6 x 103/µL (15.6 x 109/L; normal range: 4.4-11.3 x 103/µL), as well as a microcytic, hypochromic anemia (with a hemoglobin of 9.2 g/dL [92 g/L], a mean corpuscular volume of 76 μ/m3 [76 fL], and a mean corpuscular hemoglobin of 21.6 pg/cell).

What is the condition responsible for the abnormal skin findings?

Hint: Often diagnosed in the teenage years, this condition presents with epistaxis or gastrointestinal bleeding. Patients are likely to have multiple family members with the same condition.
A..Dermatomyositis
B..von Willebrand disease
C..Osler-Weber-Rendu syndrome
D..Louis-Bar syndrome