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Hello team! Posting on behalf of a colleague. Colleague would like to know our thoughts regarding the etiology of the ulcer and if ok to proceed with surgical debridement.

47 y/o male with hx pancreas/kidney transplant, htn, DM 1

1/20/20 Originally treated for cellulitis vs venous insufficiency per derm and given emollients and compression hose

3/18 began having confusion and worsening cellulitis, wife brought to ED and patient dx with AMS, AKI, ARF, and grew strep/enterococcus from rle swab in ED

Patient declined and was intubated but has recovered to step down care. His RLE issue persists and appears much worse. I was asked to see him today as he is scheduled for operative debridement tomorrow 3/25. His wound appears atypical and I'm concerned for vasculitis, NLD, calciphylaxis or other process involving pathergy. Given DM and renal history.

Last labs
Creat 2.39
Bg 304
Nominal elevation in LFTs
Procalcitonin 3.1
wbc 3.97/low
H&H 9.8/29.5
Plt 100

ABIs nondiagnostic secondary to inability to apply cuff over RLE wounds, without ability to obtain waveforms--triphasic at level of SFA on right (80mmhg vs 136 brachial at this level)

Can't have CTA secondary to creat/aki.

Thoughts? Thanks!
Mar 25, 2020 by Elaine Horibe Song, MD, PhD, MBA
5 replies
Cathy Milne
APRN, MSN, CWOCN-AP
I will be interested to hear my other colleagues thoughts on this. I agree that this is an atypical presenting wound in a very complex patient. I’m wondering if the patient’s IVC pumps are a large contributing factor to this as most of the damage appears to be posterior. The length of the wounded area and the distal tibial necrosis(? tendon..unable to discern with the picture) I have to think that there may be an element of pressure also as there is more damage on the posterior aspects. It would be nice to know what kind of medications this patient is currently on and what medications he may have received over the last month that could have contributed to the etiology of this wound. Clearly his platelets are low, which also contribute to the discoloration...
Mar 25, 2020
Eugene Worth
MD, M.Ed., FABA, ABPM/UHM
Wow!! This is a complicated patient. I'd say that all the diagnoses you have stated are pretty good. Calciphylaxis is a stretch ... but, minor quibble.

I'm suggesting a measured and targeted approach to a difficult and unknown wound. Bob Kirsner, in a paper probably 8 years ago, took a series of 350 wound biopsies, 104 of them were 'atypical.' He studied biopsy results from the 104 ... 24 were neoplasm, 14 were pyoderma, and 16 were vasculitis. So, a pathology diagnosis in over half of the 'atypical' wounds.

Tang JC, Vivas A, Rey A, Kirsner RS, Romanelli P. Atypical Ulcers: Wound biopsy results from a University wound pathology service. Ostomy Wound Management 2012;58(6):20-29.

A paper by Wirthlin (vascular surgeon) and colleagues looked at making diagnosis of wound types and severity by photograph alone. Bottom line is that wounds were over-classified and over-treated. So, I'll pass on doing that except to say that the wound looks 'wet' and would probably cover most open areas with an absorptive foam. If the leg could stand it ... also consider mild concentric compression (double layer of Tubigrips).

The measured approach to this wounding is to get multiple biopsies. I would use an excisional (elliptical) biopsy that starts in 'normal' tissue and extends into the wound base itself. Punch biopsies might give you a diagnosis but our dermatopathologist really wanted to get specimens that had 'normal' to abnormal progression at the edge of the wound. So, I would probably send at least two specimens to derm-path. I would take a third ellipse and send it to microbiology in saline (rather than fixative) asking for C&S as well as fungal cultures. The specimen gives you much more likelihood for a microbiological diagnosis rather than swab cultures.

With that said, please report back with more details.
Mar 25, 2020
Julie Lientz
MSN, MBA, RN, WCC, CWON
Definitely need biopsy to see what it is, is the patient on coumadin. Coumadin necrosis or maybe pyoderma would be my guess.
Mar 25, 2020
Elaine Horibe Song
MD, PhD, MBA
Hi team, thank you for your thoughts! Our colleague appreciates your responses and agrees with your insightful suggestions. Colleague will encourage bx and report back after the surgical debridement.
Some more info: regarding meds, patient is taking several - colleague shared a list (attached) but can't tell which ones the patient was taking at home and which ones were initiated post admission. Coumadin is not on the list. The patient was ambulatory prior to this episode.
Thank you, will post more as soon as I hear more about it!
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Mar 26, 2020
Elaine Horibe Song
MD, PhD, MBA
Hi team, thank you for your thoughts! Our colleague appreciates your responses and agrees with your insightful suggestions. Colleague will encourage bx and report back after the surgical debridement.
Some more info: regarding meds, patient is taking several - colleague shared a list (attached) but can't tell which ones the patient was taking at home and which ones were initiated post admission. Coumadin is not on the list. The patient was ambulatory prior to this episode.
Thank you, will post more as soon as I hear more about it!
meds.jpg
Mar 26, 2020
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