Wednesday, December 28, 2005

Leg Ulcer in a Heart Transplant Patient

The patient is a 49 yo man with a one month history of a very painful leg ulcer.
He is 8 years s/p heart transplant.
His medications include: CsA, CellCept, Pred, Diltiazem, Ranitidine.
There was no history of trauma and no similar ulcers in the past. He works at a supermarket and is on his feet all day long at work.
This ulcer is periodically painful. He has had leg edema for over a year.

The examination shows an 8 mm in diameter ulcer with as slightly purulent surface and ragged edges.. The borders are grayish. The area surrounding the ulcer has 2+ pitting edema and is erythematous.



Bacterial culture shows only staph species
Peripheral pulses are present but weak.

No response to support stocking used for the past three weeks.

This is probably a venous ulcer, but it's a bit unusual for a 49 yo man. Diltiazem can cause edema.
The pain is out of proportion to what one would expect. I have known the patient for six years and he has not had pain like this before.

Please help with diagnostic and therapeutic suggestions.

5 comments:

  1. I agree this is most likely venous ulcer. Is the ulcer on the medial aspect of the ankle?
    Try to avoid aggravating factors - diltiazem may make it worse. Good supportive stockings would be, in my opinion the best alternative. I would probably emphasize a lot on local dressing- initially with H2O2/ saline and once clean I would switch to plain saline dressing covered with fusidin tulle.

    Henry

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  2. I agree completely with Henry's comments. With new onset pain, one must also consider infection, even osteomyelitis, and so a tissue biopsy for culture should be considered.

    I would consider hyperbaric oxygen if this isn't showing signs of healing in the next 2 months.

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  3. Agree with Ben and Henry. My last proposal for a randomized clinical trial was about using Centalla asciatica in a gel formulation for the treatment of venous leg ulcers. Primary results in an open trial were encouraging...omid

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  4. Because of the immunosuppression, I would also biopsy the edge of the ulcer for culture to exclude opportunistic infection (eg, atypical mycobacteria). If that is negative, I would think it most likely is a stasis ulcer with livedo vasculopathy being a distant consideration because of the pain. As a stasis ulcer, I would consider applying mupirocin cream to the ulcer then covering the ulcer with DuoDedrm dressing to be left in place for 3-5 days. I might also consider applying an Unna Boot over the DuoDedrm for the compression effect, pain relief and ulcer protection. Best of luck.
    ---Rick Sontheimer

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  5. I agree,this is a vascular ulcer but whether venous or arterial,is not always easy to say.As a therapy, I suggest to give a topical HONEY as antibacterial,healing and drying agent tds alone or mixed up with fucidin.Also systemic zinc sulfate 100mg tds is helpful for venous ulcer and as immunomodulating drug.Bed rest is very essential in any leg wound or ulcer plus other supportive measures.If no responce,one can increase the dose of oral prednesone.
    khalifa sharquie

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