77 year old male with complex past medical and surgical history including:

• diabetes mellitus
• end-stage renal disease (hemodialysis dependent)
• atrial fibrillation
• coronary artery
• disease, myocardial infarctions
• ischemic cardiomyopathy (ejection fraction of 30%)
• hypertension
• hypercholesterolemia
• congestive heart failure
• pulmonary hypertension
• cervical spinal stenosis
• end-stage renal disease
• abdominal aortic aneurysm repair
• right foot transmetatarsal amputation
• cataract surgery bilateral
• depression
• gout
• gastroesophageal reflux disease

Patient consulted by dematology to evaluate progressive large retiform  palpable purpuric plaque on the abdomen. It was associated with overlying bullae a firm tender dermal hardening.

clinical image