Hematidrosis, Hemolacria, and Gastrointestinal Bleeding

blood urea nitrogen 61 mg/dL; creatinine 3.3 mg/dL; Creactive protein 19 mg/L, and INR 1.0. Urinalysis showed 1,178.7 mg/dl of proteinuria, with 3–5 red and white blood cells per high-power field, without dysmorphic cells. Total cholesterol (353 mg/dL) and triglyceride (261 mg/dL) were increased, and serum protein electrophoresis revealed hypoalbuminemia (1.8 g/dL). In a 24-h specimen of urine, protein was 2,716 mg. During hospitalization, the patient developed a sudden episode of hematemesis. On physical examination, he had hemodynamic stability and epigastric tenderness without guarding or rebound tenderness. The upper endoscopy showed diffuse mucosal redness, small ring-like petechiae, submucosal hemorrhages, and superficial ulcers in the gastric body, antrum, and duodenum ( Fig. 1 ). There was a rapid clinical deterioration, with the development of hemolacria (bloody tears), hematidrosis (bloody sweat), macroscopic hematuria, and appearance of a palpable purpura on the lower limbs, abdomen, and trunk ( Fig. 2 ). The patient developed multiple organ failure and required hemodialysis and mechanical ventilation. Given the clinical set, we considered the diagnosis of a vasculitis and started corticosteroids (1,000 mg of methylprednisolone per day). A chest high-resolution computed tomography scan was performed, and besides