Wednesday, January 20, 2021

A 50 year-old man with fever and necrotizing leg ulcers

Presented by Dr. Henry Foong
Ipoh, Malaysia

The patient is a 50-year-old chef who presented initially with blisters on the left leg. Within 3 days, the leg had swollen, painful with redness over the left leg.  He was admitted to the local hospital and was treated by an orthopedic surgeon for cellulitis for 10 days.  He requested AOR (at own risk) discharge and came in to seek for 2nd opinion.  His other medical history included COAD and hypertension.

Physical examination revealed an anxious man, breathless, tachyphniec with hight temperature of 38 deg C. His left leg appeared edematous, extensively inflamed from the foot to the knee, tender, with 3 large and deep necrotic with sloughy ulcerations on the left lateral malleolus, dorsum of left foot and ankle. There was no purplish or undermining edge. The peripheral pulses dorsals pedis was good.

Diagnosis: Necrotising cellulitis left leg

Swab was taken from the leg wound but did not grow any pathogens. He was started on IV ceftriazone 1 gm bd, wash with dermazine solution, bactigrass followed by gamjee dressing.  His blood counts and biochemistry was unremarkable except severe hypoalbuminemia. He was given IV albumin 50mg daily for 3 days.  A skin biopsy was done to exclude pyoderma gangrenosum.  His CXR showed hyperinflated lungs suggestive of emphysema.  His X ray of the left was unremarkable. His fever persisted. What kind of wound dressing would you recommend? What other empirical antibiotics would you recommend - the culture did not grow any pathogens. 
 
Reference:
1. Unna Boot Efficacy in Dermatologic Diseases

Gabriella Santa Lucia et. al.J Am Acad Dermatol. 2020 Nov 25;S0190-9622(20)33059-0.

Conclusion: Unna boot (UBs) are an inexpensive and noninvasive treatment strategy in which compression, antioxidants, physical restraint, and improved topical medication absorption enhance healing as well as quality of life measure. Even though the UB has been employed successfully by dermatologists for over a century, prior research regarding diseases treated, concurrent therapies used, and adverse events reported is minimal and UBs remain underutilized. Our findings suggest clinicians should consider using UB for a wide variety of dermatologic diseases when conservative management is a viable option. These results highlight that UBs are effective and well tolerated across a spectrum of pathologies, but also versatile in the locations where they can be applied.




5 comments:

  1. Dr. Cheng Leng Ong, Malaysia writes:
    In this part of the world, the following diagnoses are possible:-

    1. Ecthyma gangrenosum caused by pseudomonas aeroginosa, as there are some blue or black pigments in the ulcer. However, the culture is negative, which can be due to antibiotics given earlier by the orthopaedics. Ceftriazone should be working unless his general health is too poor, with severe hypoalbuminemia, hypertension and respiratory impairment. General physician may be called to make sure he does not have right heart failure due to pulmonary edema and arising from hypoalbuminemia. A change to an effective quinolone may be considered.

    2. In our part of the world, melioidosis must be considered. It is difficult to culture and a great clinical mimicker. I.V. Ceftazidime is usually effective.

    3. Necrotising facilities that’s slower than usual may be considered?

    The lesion does not look too exudative, and simple absorbent dressing may just do once appropriate antibiotic is started. Otherwise pico dressing can be used to reduce the discharge for faster healing.

    ReplyDelete
  2. Once you have cleared whatever infection this man may have had, an Unna boot, may be an inexpensive modality that will promote healing while allowing him to resume his activities of daily living. It can be changed weekly. I added a recent reference on the Unna boot to the case report.

    ReplyDelete
  3. Prof. Bhushan KumarJanuary 25, 2021

    Occlusive bandaging will definitely delay healing. UV rays help in healing, are sterilizing and safe.
    Too much use of local antiseptic creams / lotions- also kills the resident flora and delays healing.
    If the sole purpose of Una Boot is immobilization then at least during the hospital stay – active ankle exercises and elevation of the part- will increase circulation and reduce edema and promote healing.
    Too many long courses of antibiotics only delay healing. Minocycline is a good antibiotic with moderate antibacterial activity and is also anti-inflammatory- and has been found useful.
    Less therapy will be more useful than over therapy.


    ReplyDelete
    Replies
    1. Thanks, Bushan. Great suggestions. Less is often more!! If possible the patient should get out of the hospital. Hopefully, Dr. Foong will follow him as an outpatient.

      Delete
  4. From Dr. Zachary Long, Plastic Surgeon, Pittsfield, Massachusetts: …. It looks like either really bad venous stasis ulcerations or maybe some old burns that haven’t been able to heal. I would say all of that eschar and devitalized tissue needs to be debrided and covered with Silvadene daily. All of the superficial wounds could be covered with skin grafts. The area around the medial ankle is tricky though… Looks pretty deep and it wouldn’t surprise me if there is some exposed bone after debridement. Ideally, if he has good blood flow to his leg, he should have it covered with a free flap. If he doesn’t have access to that, or his vessels aren’t great, I would say they could try a dermal substitute, like Integra, then let that incorporate and granulate in (if the Integra doesn’t get infected), then skin graft over it. If that’s not available, a wound VAC with a white sponge over any exposed bone may get some granulation tissue to fill in, it will just take a while.

    ReplyDelete

We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to djelpern@gmail.com. Thank you.