Petechiae on the Fingertips as Presenting Symptom of Dermatitis Herpetiformis Duhring

A 33-year-old man with a 6-month history of recurrent petechiae on his fingertips, without any history of trauma or repetitive pressure, was diagnosed with dermatitis herpetiformis Duhring and celiac disease. Physical examination revealed grouped petechiae on the volar and lateral aspects of the fingertips. A punch biopsy showed focal separation of the epidermis from the papillary tips and neutrophilic infiltrates in the dermal papillae, while direct immunofluorescence showed granular IgA deposits at the dermo-epidermal junction. Elevated IgA antibodies to tissue transglutaminase (68 U/mL) and a duodenal biopsy indicating microerosive chronic duodenitis and villi flattening confirmed the diagnosis. A gluten-free diet led to the prevention of new petechial lesions and gastroesophageal reflux, and a decrease in tissue transglutaminase levels to 24 U/mL after 10 weeks. The case highlights that digital petechiae and acid regurgitation can be the only presenting symptoms of these conditions, and that a gluten-free diet can be an effective treatment. Dermatitis herpetiformis is a rare autoimmune dermatosis associated with gluten sensitivity, and while it is more commonly characterized by papulovesicular eruptions on extensor surfaces, this case demonstrates that petechiae on the fingertips can also be a manifestation.