Case Study of a Patient with a Chronic Lower Extremity Wound
CASE PRESENTATION
The patient is a 66-year-old white female who was evaluated for a stagnant lower right leg wound. Although the patient could not remember the exact time frame or circumstances under which she developed the lesion, she attributed its occurrence to a minor trauma. Her medical history is extensive and includes anemia, mild liver failure secondary to hepatitis C virus, hypertension, coronary artery disease, cholelithiasis, deep venous thrombosis (DVT), remote history of colon polyps, and an unspecified neuropathy given a diagnosis of mononeuritis. She also had been diagnosed with Parkinson’s disease secondary to poor gait and balance, and has a psychiatric history of depression, atypical psychosis with depressive features, general anxiety disorder, and obsessive-compulsive behavior.
The patient’s past surgical history included pacemaker placement for cardiac arrhythmia, and inferior vena cava (IVC) filter placement for the aforementioned DVT. Social history was positive for tobacco use (approximately 1 pack per day for 40 years), no alcohol or drug use. Family history was noncontributory. Current medications: ursodiol 30 mg 3 times a day, olanzapine 2.5 mg twice a day, gabapentin, acetaminophen/oxycodone, metoprolol, lansoprazole, clonazepam, acetaminophen/propoxy-phene, mirtazapine, carbidopa/levodopa, and warfarin. She has no known drug allergies. The patient appears older than her stated age. Due to progressive immobility and decline of independent function, the patient was admitted to a long-term care facility in July 2003. The wound care team was consulted in October 2003 to evaluate a skin lesion on the medial aspect of her right leg that was nonhealing, recalcitrant, and stagnant. Review of her medical records indicates that the ulcer had been mentioned as far back as January 2003.
INVESTIGATION
The initial physical examination was unremarkable. The right lower extremity had an open, irregularly shaped, shallow wound that measured 2.0 cm in length, 2.0 cm in width, and depth was questionable secondary to the wound bed containing 100% slough that was fibrinous and adherent to the underlying tissue. The surrounding skin appeared hyperemic and minimally swollen with marked vascularity. There was 1+ to 2+ swelling of the lower extremities and the etiology was suspected as being venous in nature. Initial treatment recommendations included topical papain-urea with protective dressing and leg elevation, as well as wound debridement. The following four weekly assessments found the dimensions of the lesion progressively increasing: 2.8 cm x 1.3 cm; 3.0 cm x 1.0 cm; 3.5 cm x 1.4 cm; 4.0 cm x 1.6 cm x 0.2 cm. Each week except the last the wound had 100% slough; in the last week, the wound bed was 50% slough and 50% granulation tissue. During the next 3 months, the dimensions of the wound fluctuated.
Treatment regimens included normal saline cleansing, papain-urea, papain-urea with cadexomer iodine, sodium carboxymethylcellulose, SilvaSorb™ gel (a silver-containing antimicrobial dressing), addition of vaseline gauze, and finally, the application of Promogran™ Matrix, an oxidized regenerated cellulose and collagen wound dressing. Without progress in wound treatment, the patient was referred to a local wound care center 2 months after aggressive wound care treatment was initiated. On initial evaluation there, the wound dimensions were 6.4 cm x 3.5 cm with a questionable depth, serous moderate with 100% slough (Figures 1 and 2). Becaplermin was applied to the wound and consideration made for a skin graft. The next visit revealed the right lower extremity and periwound area to be swollen, erythematous, and inflamed, suggesting cellulitis (Figure 3).
The patient was started on 2 weeks of cephalexin 500 mg twice a day. A two-layer compression was also applied (ACE wraps to be used in the nursing home), as well as an Oasis® graft. Two weeks later, the cellulitis appeared to have cleared, but wound dimensions were listed to be 7.0 cm x 3.0 cm x 0.2 cm, with 100% slough (Figure 4). DIAGNOSIS In assessing the patient’s vascular status, a Doppler study had been performed in October 2003, which showed no significant arterial occlusive disease. There was a small plaque noted in the right popliteal artery with 25% obstruction, as well as mild venous incompetence. Given the recalcitrance of the wound following 4 months of aggressive advanced wound care, other unusual etiologies were considered as possible contributory causes, such as vasculitis or a neoplasm.
With her numerous comorbidities and complicated medical history, an insidious cause for the lesion could certainly have been an ongoing factor. For thoroughness and in order to rule out other etiologies, numerous blood and laboratory tests were ordered, which included a sedimentation rate, thyroid function tests, liver function tests, antineutrophilic cytoplasmic antibody (ANCA), antiphospholipid antibody, and rheumatoid factor. The results of all of these tests were normal. On the third visit to the wound center, three 4-mm punch biopsies were performed, taken along the margins at 3 o’clock, 9 o’clock, and from the center of the wound.
MANAGEMENT
A diagnosis of pyogenic granuloma at all three sites was made following the biopsies of the wound and surrounding tissues. Wound dimensions were 6.4 cm x 3.0 cm x 0.2 cm, with 60% slough and 40% granulation 1 week following the biopsies and the use of cadexomer iodine. Plastic surgery was immediately consulted for local wound excision and split-thickness grafting of the wound. The procedure was performed within 2 weeks of the diagnosis.
DISCUSSION
Current data suggest that more than 5 million people suffer from chronic, nonhealing wounds in the United States in such various settings as acute care, home health care, and nursing homes.1-3 Given the extent to which the average age of the population is expected to increase in the coming years, the number of individuals dealing with wounds is expected to dramatically increase. It is estimated that the current costs for treating chronic wounds range from $10 billion to $20 billion annually.1-3 This financial figure is expected to rise and to impact length of hospital stay, loss of productivity, morbidity and mortality in the acute and long-term care settings, disability, and possible need for limb amputation.
Pyogenic granuloma (PG; also known as granuloma pyogenicum) is a benign vascular skin growth that often presents as a small pedunculated lesion that bleeds and oozes.4 It is relatively common and usually follows a minor injury or burn, developing rapidly after the initial trauma. This post-traumatic reaction is histologically characterized by having numerous capillaries and stroma that is edematous. There is exuberant overgrowth of granular tissue that is rich in vascular channels, and the lesion often evolves over several weeks to a size between 1 and 10 mm in diameter. It occurs in skin and mucous membranes; the most common sites include the head and neck, hands and feet, and upper trunk. PG can also be due to a chronic localized infection, and the lesion has been known to become worse following a diagnostic skin biopsy.
The exact etiology of PG is unknown, but elements contributing to its development include trauma, infection, drug and hormone effects, and angiogenic growth factors. It is seen most commonly in children and pregnant women (so-called “pregnancy tumor”) where it is characterized by lesions of the gingiva that usually regress spontaneously following delivery.5 Drugs associated with PG occurrence include isotretinoin, oral contraceptives, indinavir, and acitretin.6 The most common complications are hemorrhage and discomfort.
Pyogenic granuloma lesions are most often benign and rarely cancerous. They usually form as a single well-circumscribed, raw meat–appearing nodule or pustule. Definitive diagnostic workup includes a biopsy. A biopsy should be considered in a wound that does not show signs of improvement after 6-8 weeks of standard treatment, although individual cases may warrant a variant approach. Treatment regimens involve wound debridement, cauterization (to reduce the chance of recurrence), cryotherapy, electrodesiccation, sclerotherapy injection, discontinuing causative medications, certain chemicals (phenol, podophyllin, silver nitrate), argon and carbon dioxide laser surgery (the treatment of choice for a full thickness PG lesion), and surgical excision.
Although prognosis is extremely favorable, half of PG cases recur following treatment, sometimes occurring as multiple smaller lesions (called “satellites” or “satellitosis”). Most untreated lesions will eventually become atrophic and gradually regress. This case illustrates the daunting task that wound care specialists, podiatrists, geriatricians, and general practitioners face when a patient with multiple medical problems presents with a chronic wound. It is important to appreciate the various factors that may contribute to the development of a wound; possibilities include the common etiologies of arterial (related to peripheral vascular disease), venous, vasculitic, diabetic, traumatic, and due to pressure.
Venous and arterial ulcers constitute approximately 80% of all ulcers on the legs. Recent research has focused on the deleterious contribution infections and heavy bioburden have on delaying the rate of wound healing.7 Central to this is the biofilm, described as a multitude of interconnected microorganisms surrounded by an extracellular polymeric matrix that is resistant to numerous antimicrobial agents and host defenses.8,9
Unusual and rarer considerations in the differential include metabolic disorders, genetic diseases, vasculitis and inflammatory processes, collagen and connective tissue disease, inflammatory bowel disease (such as Crohn’s), sarcoid, Goodpasture’s, neoplasms, cryofibrinogenemia, calciphylaxis, sickle cell disease, drug-induced disease (such as by steroid use), and pyoderma gangrenosum. Pyoderma gangrenosum (not to be confused with pyogenic granuloma, which this patient had) is a destructive, necrotizing ulceration of the skin, most commonly affecting the thighs, buttocks, calves, and face.10 It causes a chronic neutrophilic inflammation that produces painful lesions,11 and may be related to pathologic gastrointestinal conditions such as ulcerative colitis, Crohn’s disease, and diverticulosis. However, its pathophysiologic mechanism is not known. It is also associated with chronic active hepatitis, rheumatoid arthritis, and multiple myeloma (all of which can cause anemia).
Our patient demonstrated numerous possible contributory factors, such as a history of gastrointestinal maladies, as well as a mention of mononeuritis (an associated feature of a vasculitic process, which includes cryoglobulinemia [also related to hepatitis C virus]) and polyarteritis nodosa (related to abdominal pain, anemia, and acute renal failure). These lesions often occur after minimal trauma and enlarge rapidly in size. They are typically characterized as having a blue-colored edge and wound tunneling. It is considered a diagnosis of exclusion; multiple laboratory tests are used to determine the presence or absence of an inflammatory or vasculitic syndrome using sedimentation rates, antiphospholipid antibodies, and liver function tests. A biopsy is required to rule out cancer or infection.
Treatment includes the use of systemic steroids and immunosuppressants, such as azathioprine and cyclosporine. Debridement often causes the wound to enlarge due to the pathergy response. Vasculitis, an inflammation of the walls of blood vessels, is due to an autoimmune process with deposition of immune complexes into tissue and/or complement activation. General signs and symptoms include multiorgan disease, arthritis, kidney failure, and skin rashes. Local inflammation leads to a decrease in blood flow to the skin and subcutaneous tissues, causing ischemia and eventual ulcer development. Vasculitic wounds are often irregularly shaped. The base of the wound is often necrotic and very vascular with reddened periwound skin. Cutaneous manifestations include palpable purpura, petechiae, and persistent urticaria. Consideration of a neoplasm should always be in the clinician’s mind. Diagnosis is made by tissue biopsy to rule out an epidermoid-type of carcinoma, such as may arise from chronically irritated tissue (ie, Marjolin’s ulcer), and could be a basal cell carcinoma, squamous cell cancer, or melanoma.12,13
OUTCOME
After excision and graft placement, the patient complained of pain at the post-surgical site (Figures 5 and 6). Although she had an uneventful recovery and the graft did take to the wound bed, the process took nearly 2 months, and her rehabilitation was slowed due to noncompliance after returning to the nursing facility. The patient continued to use tobacco and was not elevating her legs as much as recommended. Eventually, with continued urging from the medical staff for her to make these practical and lifestyle changes, the wound healed. This case had a successful outcome. In retrospect, it would have been reasonable to have had the patient evaluated in the wound care center sooner, and to have performed a skin biopsy earlier in the course of treatment. Not knowing what type of wound care the patient had received prior to the wound care team’s consultation, further weeks of treatment and follow-up in the nursing facility is understandable. Health care providers should keep in mind the need to obtain tissue for a chronically fluctuating skin lesion in order to make a definitive diagnosis.
The research reported in this article was supported by Vohra Health Services and North Shore Medical Center, Miami, FL. Acknowledgments I would like to thank the following medical personnel and support staff without whose assistance and guidance this case review would not have been possible: Eduardo Serrano, PA-C; Andrea Jackson-Knott, RN; Patricia Quintanilla, office coordinator, North Shore Medical Wound Center; Marie Marcelin, LPN; Luis Lopez, nurse assistant; Ameet Vohra, MD, CWS, Medical Director, North Shore Medical Wound Center.
