A Surfeit of Possibilities…
Precise diagnosis of lower-extremity ulcerations is essential. Management differs so extensively between etiologies that misdiagnosis can lead to fatal outcomes. This was brought to mind when an 89-year-old woman was admitted directly to the hospital for treatment of worsening bilateral lower-extremity ulcerations. She had been transferred from another institution after a 2-week hospitalization due to concerns for calciphylaxis.
Her symptoms started with edema of the distal bilateral lower-extremities 6 weeks earlier. Edema was followed by erythema and ulceration of the lateral aspect of her legs. These ulcers were bilateral but more pronounced on her right side. They were exquisitely painful, continued to enlarge, and occasionally discharged serosanguineous material; the exudate was never pustular.
When first evaluated at her local hospital, the patient received antibiotics with no improvement in her ulcers. Two biopsies were unrevealing. She had a history of atrial fibrillation requiring warfarin for 3 years, but the drug had been discontinued a few days prior to transfer in case she was developing warfarin-induced skin necrosis.
Her past medical history also was significant for chronic obstructive pulmonary disease, dilated cardiomyopathy with an ejection fraction of 30%, hypothyroidism, and hypertension. She had no history of vascular or kidney disease, tobacco use, or autoimmune disorders. Her other medications were carvedilol, enalapril, furosemide, metolazone, and levothyroxine.
On arrival at our institution, the patient was afebrile and normotensive. Her physical exam was remarkable for irregularly irregular heart rhythm with a 2/6 systolic ejection murmur best heard parasternally. She had no jugular venous distention, and her pulses were palpable throughout. An examination of the lower extremities revealed several stellate areas of purplish purpuric discoloration with associated necrosis and ulcerations distal to the knee and most notably, on the dorsolateral aspects of her right leg (Figure 1). Some mild erythema around the ulcers coexisted with the purplish discoloration.
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– Janelle Gooden, MD, Elfriede Agyemang, MD, Jason Post, MD
This article originally appeared in the June 2013 issue of The American Journal of Medicine.
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