Welcome back to another Clinical Image of the Week from the case files of the Brown EM Residency!
HPI: 20 year old female with no significant past medical history who presents to the ED with one week of severe, diffuse abdominal pain. She’s never had this pain before. It waxes and wanes. Nothing makes it better or worse. It is associated with nausea, intermittent joint pain and swelling, and a non-pruritic rash on her lower extremities. She states she had a head cold about three weeks ago, but has been otherwise well. She denies fevers, chills, headache, shortness of breath, chest pain, nausea, vomiting, diarrhea, or urinary symptoms. Of note, she was seen at an urgent care when her symptoms started and put on doxycycline for presumed Lyme, although she denies any tick bites.
Vitals: BP 126/81, HR 73, T 98.7 °F, RR 18, SpO2 100 % on RA
Notable physical exam findings: Mild, diffuse abdominal tenderness, but no rebound or guarding. She has scattered, raised, purpuric lesions on her bilateral lower extremities. They are non-painful and non-blanchable (see below).
Notable laboratory workup: Trace, microscopic hematuria and a mildly elevated creatinine (1.24).

What’s the diagnosis?
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