When A Non-Healing Wound Has A Dermatologic Origin
A 60-year-old Hispanic female presented with the chief complaint of severe pain associated with a large wound on her left leg, which had been present for four years. She had received treatment at another local hospital prior to her admission to Maricopa Medical Center in Phoenix and the previous treatment recommended to her was a below-knee amputation. Her prior treatment while living in Mexico included application of topical antibiotics and a wet-to-dry dressing. She had never had any type of debridement of the wound.
Her past medical history was remarkable for hypertension. She denied any psychiatric disorders. The patient had no history of illicit drug use or alcohol abuse, but had a past history of smoking. Her family history was unremarkable.
The patient’s physical exam revealed a seemingly healthy looking woman consistent with her stated age. Her vitals on admission were blood pressure 95/55, pulse 98, respirations 20, temperature 38.2ºC and oxygen saturation of 92 percent. She had strong, palpable pulses without any neurologic deficits.
The dermatologic exam revealed a large, well-demarcated wound on the medial aspect of her leg. The wound encompassed the region from the tibialis anterior tendon on the lateral margin to the Achilles tendon posteriorly. Inferiorly, the wound started at the superior aspect of the heel and extended to the distal third junction of the lower leg. The wound had a mixed granular and fibrotic appearance with red and yellow tissue. There was no accompanying cellulitis. The leg was not particularly edematous.
The complete workup on this patient included a complete blood count (CBC) with differential; chemistry panel; coagulation studies; tuberculosis and coccidioidomycosis screens; hepatitis B and C screen; thyroid-stimulating hormone levels; rheumatic panel including erythrocyte sedimentation rate (ESR), rheumatoid factor, and anti-nuclear antibodies; serum levels of immunoglobulins, anti-proteinase 3 antineutrophil cytoplasmic antibodies; perinuclear antineutrophil cytoplasmic antibodies; wound and blood cultures; X-rays of the leg; magnetic resonance imaging (MRI) of the leg; venous Doppler ultrasound of the leg; and biopsy of the wound. The biopsy included a 1 cm x 3 cm triangular tissue segment to include normal and abnormal tissue to the level including muscle.
Pending results of the ordered tests, I initially placed her on empiric antibiotic coverage, which included vancomycin and piperacillin/tazobactam (Zosyn, Pfizer). She received narcotic analgesics for pain. I obtained podiatry, vascular and dermatology consults.
Key Questions To Consider
1. What are the main characteristics of this condition?
2. What is the most likely diagnosis?
3. What is your differential diagnosis?
4. How can one make a definitive diagnosis?
5. What is the treatment?
Answering The Key Diagnostic Questions
1. The patient had a large, well-demarcated wound on the medial aspect of her leg with a mixed granular and fibrotic appearance with red and yellow tissue.
2. Pyoderma gangrenosum
3. Venous stasis ulceration, vasculitis, ulceration due to arterial insufficiency, carcinomas, granulomatous diseases associated with vasculitis, pyoderma gangrenosum, anthrax or sporotrichosis
4. Biopsy and exclusion
5. Oral and topical corticosteroids, immunosuppressive agents, sulfa drugs and/or cytotoxic drugs
Keys To The Differential Diagnosis
The differential diagnosis for a chronic wound on the lower leg includes: venous stasis ulceration, vasculitis, ulceration due to arterial insufficiency, carcinomas, granulomatous diseases associated with vasculitis, pyoderma gangrenosum, and rare infectious diseases such as anthrax and sporotrichosis.