A case of non-healing ulcer

 This is an online E logbook to discuss our patient's de-identified health data shared after taking her guardian's signed informed consent. 

Here we discuss our individual patient's problems through series of inputs from an available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs. 

This E logbook also reflects my patient-centered online learning portfolio and your valuable inputs on the comment box are welcome.

MAY 15,2021

A 65-year-old female, who is a homemaker presented to the hospital with the chief complaint of a non-healing ulcer

HISTORY OF PRESENTING ILLNESS

In December 2020, the patient first complained of a small itchy papular lesion that appeared on the anterior aspect of her right lower limb which, on scratching bled easily. Soon a similar lesion appeared a few cms lateral to the original lesion and they ulcerated. The ulcers were apparently itchier than they were painful. There was an initial swelling of the skin around the ulcers that gradually subsided. 

In February 2021, a deep vein thrombosis was suspected and a doppler was conducted which showed no abnormalities inflow, hence ruling it out. The patient had no visible varicosities either. An orthopedic consultation was taken and the patient was prescribed Cilastazole for the next 20 days

That following week diffuse inflammatory changes were noted over the ulcers such as redness, pain, swelling, and this was accompanied by a fever. The diagnosis of cellulitis was made and the patient was prescribed clindamycin and cefuroxime. The patient apparently completed 2-3 cycles of these two antibiotic courses, following which she noted an improvement in her pain symptoms that were associated with the ulcer. 

At this point, the patient claims that there is a slight loss of sensation over the ulcers

In March 2021, the patient complained of a tingling sensation in both her feet for which she was given Gabapentin

Surgical debridement of the ulcer was carried out during which the two ulcers were joined

In April 2021, an autograft taken from the thigh was used to cover the patient's ulcer in an attempt to cover the defect. At this point, no prophylactic steroids were given to the patient. Autologous platelet-rich plasma(PRP)was added to the wound to facilitate healing following which the graft was was covered with a vacuum assisted closure(VAC) device. PRP was reportedly added a second time later( time not specified). In total the dressing was changed thrice.

Post grafting wound healing proceeded normally and according to expectations for the first 1 week. During the 2nd week, growth of excessive granulation tissue was noted that exceeded the margins of the original ulcer. The granulation tissue grew through the holes of the skin graft, pushing it away from the skin. In the patient's own words, the graft separated from the skin "like an onion peel" starting from the periphery, leaving only a central 30% of the original graft area still intact. 

Around a week after this, the patient became febrile and the ulcer site became swollen, red, and tender. Culture and sensitivity showed a localized pseudomonas infection for which antibiotics (Cefpodoxime and metronidazole) were prescribed. 

 There have been no complaints of oozing discharge from the ulcer or excessive pain. Overall, the ulcer has affected the patient's mobility and has not healed in spite of past interventions. 

Progression of the ulcer in the month of May 2021:

21st May 2021:

22nd May 2021: 

23rd May 2021:

24th May 2021: 

27th May 2021:

On 2nd June 2021, a second graft was placed.

PAST HISTORY

• The patient was diagnosed with hypertension at the age of 35
  
  
• She had a fracture of the lower limb(side and site unspecified) 15 years ago. Even though it healed without complications, the patient still complains of mild pain and discomfort while walking.
  
  
• The patient was diagnosed with osteoporosis 5 years ago
  
  
• She has a history of recurrent itchy rash all over her body, which response to topical steroids. The allergen is not known.
  
  
• The patient apparently developed blackish discoloration associated with itching on both her lower shins and dorsum of feet (at the site of previous pedal edema) 2 years ago. The discolored skin doesn't show any redness or swelling and on touching resembles normal surrounding skin. The itch subsided with the use of a topical steroid cream
  
  
• No history of DM-2, TB, asthma, epilepsy

PERSONAL HISTORY

• Diet: Mixed
• Appetite: Slightly decreased
• Bowel and bladder: Normal
• Sleep: Adequate
• Addictions: None

DRUG HISTORY

• Amlodipine+Atenolol (Stamlo beta 5mg) which was discontinued on account of pedal edema 3 months ago
• Telmisartan (Telma 40) and Metoprolol succinate (Met xl 12.5mg)
• Etizolam and propranolol tablets ( Etizola beta 0.25mg) for the past 3 years 
• Clobetasol propionate and fusidic acid cream (Niosol-F) for 2-3 months on account of itching(discontinued)
• Cilostazol for 20 days, 4 months back in February (discontinued)
• Cefpodoxime and Metronidazole in March
• Gabapentin for 1 month in March (discontinued)
• She takes Calcium supplements (ShelCal) and multivitamins

FAMILY HISTORY

• No similar complaints in the family
• Family history of hypertension (+)
• Family history of obesity (+)

GENERAL EXAMINATION

• The patient is conscious, coherent, cooperative
• She is well orientated to the day, time, person, and place
• She is moderate to heavily built with central truncal obesity

Height: 157cm            Weight: 80kgs (BMI: 32.5)

1. Pallor: Absent
2. Icterus: Absent
3. Cyanosis: Absent
4. Clubbing: Absent
5. Lymphadenopathy: Absent
6. Pedal edema is present bilaterally 

An ulcer is visible on the anterolateral aspect of the right leg, above the lateral malleolus

Vitals (at the time of admission):

• Temperature: afebrile
• Pulse rate: 78bpm
• Respiratory rate: 20cycles/min
• BP: 140/70mmhg, left arm, sitting position
• SpO2: 98 % at RA

SYSTEMIC EXAMINATION

• CVS: S1, S2 heard
• Respiratory: Bilateral Air Entry positive
• Per Abdomen: Soft and non-tender, bowel sounds heard

INVESTIGATIONS

1)COMPLETE BLOOD PICTURE

ABNORMALFINDINGS

 Hemoglobin: 11.6g/dl

MCH:24.4pq

MCHC:26.4g/dl
RDW-SD: 55.6fL
RDW-CV:16.2%

2) GLYCATED HEMOGLOBIN

(Normal)

3)LIPID PROFILE

Abnormal findings: TC/HDL CHOLESTEROL ratio: 2.4

4) TOTAL VITAMIN D

(Normal)

5)TESTOSTERONE

                                                                           (Normal)

6) IRON, TIBC, %TRANSFERRIN SATURATION

(Normal)

7)THYROID PROFILE

(Normal)

8) LIVER FUNCTION TEST

(Normal)

9) eGFR

(Normal)

10) KIDNEY FUNCTION TESTS

Abnormal findings:
 BUN: 30.79
Urine calcium: 8.53mg/dl

11) FASTING AND POST LUNCH BLOOD SUGAR

Fasting blood sugar: 81.0ng/dl
Post lunch blood sugar: 117ng/dl

12) VENOUS COLOR DOPPLER

Impression: Mild cellulitic changes from lower 1/3rd of leg to foot level on both sides(right>left)

13) URINE EXAMINATION

14) SKIN BIOPSY

Impression: Chronic non specific dermatitis


15) BACTERIAL CULTURE AND SENSITIVITY REPORT

Culture report positive(+) for E. Coli and Pseudomonas

DIFFERENTIAL DIAGNOSIS

• Venous ulcer
• Arterial ulcer
• Hypertensive/Martorell's ulcer
• Cortisone ulcer
• Gummatous ulcer
• Chronic osteomyelitis
• Erythrocyanosis Frigida