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British Journal of Dermatology 1996; 134: 915-918.
Leucocytoclastic vasculitis induced by prolonged exercise
M.PRINS, J.C.J.M.VERAART, A.H.M.VERMEULEN,* R.-F.I-I.J.HULSMANS AND
H.A.M.NEUMANN
Departments o f Dermatology and *Pathology, Acadmusch Ziekenhuls, Maastricht, P. Debeyelaan 25, Postbus 5800,
6 2 0 2 A7j Maastricht, the Netherlands
Accepted for publication 16 August 1995
Summary
Many people develop skin symptoms after long-distance walks, but little is known
aetiology of these. In this study we took 11 biopsies from 10 long-distance walkers who walked
80 km. All biopsies originated from purpuric lesions on the lower legs, which had appeared during
walking. In all 1 1 specimens, signs of a leucocytoclastic vasculitis were present with leucocytoclasis,
exocytosis of erythrocytes and a granulocyte/mononuclear perivascular infiltrate. Immunofluores
cence investigations showed deposition of C3c in many specimens and immunoglobulin M in some.
The occurrence of a leucocytoclastic vasculitis after prolonged exercise may be explained by the
existence of an exercise altered cutaneous microcirculation, complement activation and an altered
immune function.
Worldwide there is a growing interest in sports and
sports medicine. We have seen a patient who developed
erythema, purpura and an histological proven leucocy
toclastic vasculitis on the lower legs, which only
occurred after walking at least 30 km. There have
been several reports of exercise-induced purpura and
urticarial lesions.1“ These were mostly attributed to
local pressure from shoes or clothing, or solar influ
ences. However, purpura of the legs, in particular the
lower leg region in association with sport, has not been
we visited the finish of a long-distance walk to investi
gate the prevalence of skin symptoms such as erythema,
urticaria and purpura, and to study venous function.
is known to
venous
9'5 ± standard error 5-6 s; normal
> 25 s) as an i
of
of
we report
venous system In this í
zs in ;
c
ical lì
a long walk.
Irom wt
■f
Patients and methods
Fifty-eight long-distance walkers (40 males, 16 females,
sex in two not registered) were evaluated within 1 h
following an 80 km m arch (Kennedy mars, Someren,
the Netherlands). The participants were
gave verbal informed consent. Their legs were exam•: H .A .M .N eum ann.
«') 1 9 9 6 British A ssociation of Dertru
ined for erythema, urticaria, purpura and chronic
venous insufficiency (CVI). Skin changes due to CVI
were staged according to Widmer et ah and classified as
either absent, or present in a mild or severe form,
four participants were evaluated for venous ini
dency by light reflection rheography
using
a
Laumann
r
1000 Rheograph (Selb, Germany).1 None of the volun
teers was examined before the walk and no data on
medical history or medication were known.
a, urticaria and purpura were described as
as a transient
or present. E
2ma was
local redness of the skin, disappearing after local pres
sure. Purpura was distinguished from erythema when
failed to blanch the lesion, in 10 participants,
two 4 mm punch biopsy specimens were taken from a
representative purpuric lesion on the lower leg; in one
participant, two series of biopsies were obtained, one
series of biopsies from each leg. No biopsies from other
sites of the body nor from controls were taken. One of
the two specimens was snap-frozen in liquid nitrogen
and stored at ~70"C. Cryostat cut 4 /mi sections were
stained with fluorescein-conjugated rabbit anti-human
I
in A (IgA), IgC)
ies to Clq, C3c, immunog
up, Denmark). The
and IgM and fibrin (Dako, ( I
specimen was
paraffin and stained with haematoxylin and eosin. Both
specimens were evaluated by one pathologist and one
dermatologist. To standardize the histological features
of leucocytoclastic vasculitis, grading criteria were uf
: epidermal changes, specially
'* 1
915
916
M . P R I N S et al.
Table 1. D istribution of oedem a, varicose veins, skin ch an g es as sign of
chronic venous insufficiency (CVI), e ry th e m a and p u rp u ra after
w alking 8 0 km in 58 v o lu n teers
A bsent
P resen t
Oedem a
24
Varicose veins
30
Skin ch an g es as sign of CVI
45
E rythem a
P u rp u ra
P u rp u r a and e ry th e m a
U rticaria
33
48
52
50
M oderate in 2 2
Distinct in 12
M inor in 19
Stem in 9
Mild in 9
Severe in 4
25
10
6
8
necrosis; exocytosis of erythrocytes; depth of infiltrate;
vessel wall invasion by neutrophils; amount of leucocytoclasis and amount of fibrinoid necrosis. All criteria
were graded as absent, marginal or distinct.
Results
In 41 of the 58 volunteers erythema and/or purpura
was seen (Table 1). Coexisting urticarial lesions were
observed in eight cases. According to the volunteers, all
lesions had appeared during the walk, and were pain
less. Some were palpable. The purpura were signifi
cantly more frequent in participants who had distinct
oedema, saphenous vein varicosity, and/or severe skin
changes due to CVI. The occurrence of the purpura and
erythema was more frequent in females, but the skin
symptoms of CVI showed no sex difference.
All 11 biopsies showed leucocytoclastic vasculitis
Biopsy
n u m b er
1
2
3
4
5
(y
7
8
9
10
11
Histological
LCV
+
+
M
|A
M
H"
1
■
ii‘|■i
+
I m m u n o g lo b u lin s
C3c
IgM +
---
-,
I*|™
’
“1“
IgM-b
—
---
Discussion
Leucocytoclastic vasculitis (syn: allergic vasculitis, leu
cocytoclastic angiitis) is characterized by palpable
purpura due to deposition of immune complexes in
postcapillary venules, primarily of the legs.8 Any
other organ, apart from the skin, can be involved.
Several factors influence the disease activity, including
the concentration of circulating immune complexes, the
half-life of the complex and
of the antibodies which form the complexes. In many
cases the disease is self-limiting, and only confined to
the skin. Leucocytoclastic vasculitis can be triggered
by many factors including bacterial infection, drugs,
immune complexes, blood stasis and systemic
Prolonged exercise can now be added to this list.
P u rp u ra
E rythem a
Table 2. H istological and im m u n o
fluorescence results, in com bination with
the clinical a p p e a ra n c e of the lesion
+
IgM +
—
C lq
(Table 2), with a mild to severe leucocytoclasis, granu
locytes and mononuclear cells invading the vessels
11), marginal exocytosis of erythrocytes (n 3 ) ,
(n
and exocytosis of the infiltrate into epidermis (n = 2 )
(Fig. 1). Fibrinoid necrosis, epidermal necrosis or fibrin
thrombus formation were not found. On immunofluor
escence, all but one specimen revealed C3c deposition in
the subepidermal capillaries. In one case, granular C3c
was stretched out along the basement membrane. In
another, it was also found in the papillary dermis. Clq
was found, in two specimens, in the mid-dermis. igM
distribution was seen in four; three times in the capil
lary loop and once mid-dermal. One biopsy was nega
tive for all antibodies. The infiltrate varied in depth from
being superficial and perivascular, i
mainly the
papillary dermis, to involving the subcutaneous fat with
vessel wall invasion by neutrophils.
+
+
+
«■|
t‘i^|‘.V
—
++
-
H—b
_H_
—
W
l'l'H
«
H—h
--
f
+
"I"
"I“
4"
1»|H
—
.—
LCV, leucocytoclastic vasculitis; p u r p u r a a n d ery th em a:
absent, -|- = present; im m
bulins, C îc and C lq :
absent, + = m a rg in a l, + + = distinct. Biopsies 5 and 6 cam e from
different p u rp u ric lesions o n different legs of th e sam e long-distance w alker.
© 1 9 9 6 British A ssociation of Dermatologists, British journal of D m m ito h a u , 1 Î4 , 9 1 5 - 9 1 8
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