Vicious Vanco: Vancomycin-Induced Cutaneous Small-Vessel Vasculitis in a Patient With End-Stage Renal Disease

Vancomycin is a first-line antibiotic used for severe gram-positive infections, but it may rarely trigger immune-mediated small-vessel vasculitis. We report a case of a 43-year-old man with end-stage renal disease on home hemodialysis who developed palpable purpuric skin lesions three days after starting vancomycin for L5-S1 discitis and osteomyelitis. Over the following days, the eruption progressed into symmetric, non-blanching purpuric plaques involving the upper and lower extremities by day 6 of therapy. Laboratory evaluation demonstrated progressive thrombocytopenia, an increase in eosinophil counts within the normal reference range, and elevated inflammatory markers, which declined after vancomycin cessation. Vancomycin was discontinued, and antimicrobial therapy was transitioned to daptomycin, resulting in rapid clinical improvement within 48 hours and near-complete resolution by day 12. This case emphasizes the importance of early recognition of vancomycin-induced leukocytoclastic vasculitis, particularly in patients with renal impairment who may experience an accelerated onset. Prompt discontinuation of the offending agent typically results in rapid recovery without the need for systemic corticosteroids.