#00066306

A 44-year-old male presented with sudden onset weakness of the left upper limb, ataxia with slurring of speech and excessive sweating. He was managed as a case of cerebrovascular accident with Right Middle carotid territory infarct. He was a known case of anterior wall myocardial infarction with percutaneous coronary intervention done Left anterior descending artery in 2008 and history a posterior circulation stroke in 2019. In early Sept 2025, the patient developed multiple retiform purpurae seen over the lower one-third of the leg, bilateral feet and left forearm, and there was necrosis and ulceration. A dermatology review was done, and a skin biopsy was advised. Skin biopsy of a necrotic plaque revealed extensive dermal thrombosis with hemorrhagic ischemic change and a neutrophilic infiltrate. The biopsy findings confirmed the clinical suspicion of severe cutaneous thrombosis with hemorrhagic necrosis. Meanwhile Flowcytomtery for paroxysmal nocturnal hemoglobinuria was done using CD24, CD14 and FLAER, which showed a 99.96%clone in the neutrophils and 11.40% clone in the monocytes.