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images in clinical medicine Lindsey R. Baden, M.D., Editor

A Blinking Knee

Jeffrey D. Lazar, M.D., M.P.H. Lucy K. Willis, M.D. New York–Presbyterian Lower Manhattan Hospital New York, NY [email protected]

A

30-year-old woman with no notable medical history presented with a 1-day history of spreading redness, swelling, and blistering of her left leg, possibly due to insect bites during sleep. On presentation, the temperature was 38.3°C, the heart rate 104 beats per minute, and the blood pressure 103/70 mm Hg. On examination, the anterior middle and distal portions of the left leg were grossly erythematous, with scattered vesicles and some clear exudate. The anterior knee had a blinking appearance (see video). The patient had 2+ pulses distally and normal capillary refill in her nail beds. The results of laboratory tests were unremarkable. The patient was admitted to the hospital, and a diagnosis of an exuberant reactive dermatitis due to insect bites was made. The blinking resolved within 24 hours after its onset, and the patient had an uneventful recovery. No underlying vascular disease was diagnosed. Quincke’s sign, also referred to as Quincke’s pulse, is a physical finding of aortic insufficiency or, less commonly, focal arterial dilatation. In this case, arterial dilatation in the area of the dermatitis presumably led to an inability of arterioles to maintain sufficient pressure during diastole, resulting in the classic alternating blanching and flushing described in 1882 by Heinrich Quincke and producing in this patient a blinking knee.

DOI: 10.1056/NEJMicm1311581 Copyright © 2014 Massachusetts Medical Society.

e36

n engl j med 370;24

nejm.org

june 12, 2014

The New England Journal of Medicine Downloaded from nejm.org at PENN STATE UNIVERSITY on June 12, 2014. For personal use only. No other uses without permission. Copyright © 2014 Massachusetts Medical Society. All rights reserved.

Images in clinical medicine. A blinking knee.

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