Painful Leg Ulcers: A Misdiagnosed Case Report With Literature Review
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Leg ulcers are a common symptom in patients with vascular disease. Ninety-five percent of chronic leg ulcers are due to ischemia, stasis, neurotrophic conditions, and other conditions, such as vasculitis, hypertension, and syphilis.1 The following case report presents an uncommon cause for a leg ulcer, which was initially suspected to be a vascular disease.
Case Report
A 56-year-old man was admitted to the authors’ department with painful leg ulcers of 3 months duration. Upon examination, 12 ulcerations ranging from 10 mm2 x 10 mm2 to 50 mm2 x 50 mm2 located on the left malleolus, tibia, and the dorsal aspect of the feet and calves were found (Figure 1). Exuding ulcers were shallow with diffuse edges. Generalized edema with brown pigmented, scaly surrounding skin was noted, but there was no bone, tendon, ligament or muscle involvement. Brown discoloration of fingernails and diffuse hyperpigmentation over the entire body was present (Figure 2).
Medical history indicated that the patient had been taking a medication for 3 years to treat chronic granulocytic leukemia, which was well controlled. All 12 ulcers were initially treated with therapies including wound dressings, antibiotics, and surgical debridement, but there was no healing in any of the other ulcers. All laboratory data, including white blood cell count, platelet count, biochemical values, and blood glucose level were normal. Coombs and HIV tests were negative. A histological examination of the malleolar ulcer edge (taken from the largest ulcer [50 mm2 x 50 mm2]) found papillary dermal edema, vessel hyalinization, and perivascular lymphocytic inflammation with no vasculitis. No malignancy was seen (Figure 3). Arterial and venous angiography was performed and arterial sclerosis/stenosis, varicose veins, and deep venous thrombosis was not found. Lymphadenography was normal.
All 12 leg ulcers were fully cured 2 weeks after discontinuation of hydroxyurea and no ulceration was present at 1-year follow up.
Discussion
1. Cronenwell H, Gloviczki P, Johnston KW, et al. Initial Patient Evaluation: The Vascular Consultation. In: Rutherford RB, ed. Vascular Surgery. 5th ed. WB Saunders Company; 2000:11–12.
2. Franks PJ, Moffatt CJ, Doherty DC, Smithdale R, Martin R. Longer-term changes in quality of life in chronic leg ulceration. Wound Repair Regen. 2006;14(5):536–541.
3. Vuerstaek JD, Vainas T, Wuite J, Nelemans P, Neumann MH, Veraart JC. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg. 2006;44(5):1029–1037.
4. O'Donnell TF Jr, Lau J. A systematic review of randomized controlled trials of wound dressings for chronic venous ulcer. J Vasc Surg. 2006; 44(5):1118–1125.
5. Ogbera AO, Fasanmade O, Ohwovoriole AE, Adediran O. An assessment of the disease burden of foot ulcers in patients with diabetes mellitus attending a teaching hospital in Lagos, Nigeria. Int J Low Extrem Wounds. 2006;5(4):244–249.
6. Stock CC, Clarke DA, Philips FS, et al. Sarcoma 180 screening data. Cancer Res. 1960;20(5 Pt 2):193–381.
7. Stevens MR. Hydroxyurea: an overview. J Biol Regul Homeost Agents. 1999;13(3):172–175.
8. Chaine B, Neonato MG, Girot R, Aractingi S. Cutaneous adverse reactions to hydroxyurea in patients with sickle cell disease. Arch Dermatol. 2001;137(4):467–470.
9. Stahl RL, Silber R. Vasculitis leg ulcers in chronic myelogenous leukemia. Am J Med.1985;78(5):869–872.
10. Montefusco E, Alimena G, Gastaldi R, Carlesimo OA, Valesini G, Mandelli F. Unusual dermatologic toxicity of long-term therapy with hydroxyurea in chronic myelogenous leukemia. Tumori. 1986;72(3):317–321.
11. Best PJ, Daoud MS, Pittelkow MR, Petitt RM. Hydroxyurea-induced leg ulceration in 14 patients. Ann Intern Med. 1998;128(1):29–32.
