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CLINICA DERMATOLOGICA
PÉCS
HUNGARIA
DIFFERENTIAL DIAGNOSIS OF LEG ULCERS
- ULCERS OF RARE ETIOLOGIES
András Kovács L.¹, Zs...
• Aim : chronic wounds without a tendency to heal present a serious public
health and economic issue. With the case report...
Case 1.: ulcerative basalioma
• female patient, 91 years old
• approx. 2,5 years history of ulcers resistant to conservati...
Case 2.: leg ulcer - basalioma
metaplastic subtype
• female patient, 82 years old
• approx. 3 years history of ulcer resis...
Case 3.: squamous cell carcinoma
on the base of chronic leg ulcer
• female patient, 71 years old, post-thrombotic syndrome...
Case 4-5.: pyoderma gangrenosum
• male patient, 70 years old, a rapidly progressive ulcer with a livid-purple
coloured mar...
Case 6.: ulcer associated with lichen
sclerosus et atrophicus
• female patient, 61 years old
• skin lesions ongoing for th...
Case 7.: ulcer associated with
scleroderma - rheumatoid arthritis
overlap syndrome
• female patient, 58 years old, locomot...
angiography: no sign of arterial stenosis,
early venous filling on the right leg -
sign of chronic venous insufficiency
• ...
• Results: histological examination of ulcers without a tendency to heal performed
based on the clinical picture proved to...
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EWMA 2013 - Ep519 - DIFFERENTIAL DIAGNOSIS OF LEG ULCERS - ULCERS OF RARE ETIOLOGIES

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András Kovács L.¹, Zsolt Kádár¹, Éva Varga¹, Iván Péter¹, Mehdi Moezzi¹, Imre Schneider¹, Endre Kálmán², Krisztián Molnár³, Dalma Várszegi¹
Department of Dermatology¹, Department of Pathology², Department of Radiology³ University of Pécs, Medical School, Pécs, Hungary

Published in: Health & Medicine
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Transcript of "EWMA 2013 - Ep519 - DIFFERENTIAL DIAGNOSIS OF LEG ULCERS - ULCERS OF RARE ETIOLOGIES"

  1. 1. CLINICA DERMATOLOGICA PÉCS HUNGARIA DIFFERENTIAL DIAGNOSIS OF LEG ULCERS - ULCERS OF RARE ETIOLOGIES András Kovács L.¹, Zsolt Kádár¹, Éva Varga¹, Iván Péter¹, Mehdi Moezzi¹, Imre Schneider¹, Endre Kálmán², Krisztián Molnár³, Dalma Várszegi¹ Department of Dermatology¹, Department of Pathology², Department of Radiology³ University of Pécs, Medical School, Pécs, Hungary
  2. 2. • Aim : chronic wounds without a tendency to heal present a serious public health and economic issue. With the case reports the authors present ulcers of rare etiologies, emphasising the importance of performing differential diagnosis before treatment. • Methods : in 2012 the authors have treated 268 patients with leg ulcer in their department of dermatology. In cases of chronic, non-healing ulcers with an atypical wound and medical history histological examination was performed in order to establish a correct diagnosis. From the new patients treated in 2012 the authors present 7 cases of leg ulcers, including 6 various, rarely occuring ulcers.
  3. 3. Case 1.: ulcerative basalioma • female patient, 91 years old • approx. 2,5 years history of ulcers resistant to conservative therapy on the medial surface of the middle and lower third of the left leg • solar damage of the skin: solar keratoses, skin tumors (basal cell carcinoma) of the face and chest • ulcerative malignant tumor of the skin suspected as the possible cause of the atypical leg wounds • sampling excision from the border of the leg ulcers – histological examination • Diagnosis: ulcerative basal cell carcinoma, nodulocystic and infiltrative type • Therapy: extirpation of the tumors basalioma- nodulocystic type basalioma – infiltrative type basalioma
  4. 4. Case 2.: leg ulcer - basalioma metaplastic subtype • female patient, 82 years old • approx. 3 years history of ulcer resistant to conservative therapy on the dorso-lateral surface of the lower third of the right leg with a size of 3x2 cm • angiological examination: varicosity, chronic venous insufficiency • skin cancer has been taken into consideration as the possible cause of the atypical wound • sampling excision from the border of the ulcer – histological examination • Diagnosis: basal cell carcinoma – metaplastic subtype • Therapy: extirpation of the tumor, covering with skin graft Histology: • ulcer covered by crust • infiltrative tumor forming cellular nests • the cells do not palisade • the nuclei are vesiculated • a central nucleolus is present • the cytoplasm is mildly vacuolized and cubic
  5. 5. Case 3.: squamous cell carcinoma on the base of chronic leg ulcer • female patient, 71 years old, post-thrombotic syndrome on the left leg, varicectomy 3x, chronic venous insufficiency • recurrent ulcer, above the left inner ankle since the 1980s • 2x plastic surgery treatment of the ulcer – in the 1990s • 1998 – healing of the ulcer; 2009 – recurrency of the ulcer, conservative treatment, no tendency to heal • 2012 – sampling excision for histological examination of a 6x4 cm verrucous, hyperkeratotic tissue developed on the tibial side of the ulcer • Diagnosis: carcinoma planocellulare partim keratosum invasivum cutis, Grade 2. • staging examinations (CT - chest, abdomen, pelvis) negative • Therapy: extirpation of the ulcer and tumor, super selective cytostatic treatment administered into the external iliac artery, oncological management ← ← ←← well differentiated squamous cell carcinoma
  6. 6. Case 4-5.: pyoderma gangrenosum • male patient, 70 years old, a rapidly progressive ulcer with a livid-purple coloured margin has developed on the left leg in the region of the Achilles tendon following a minor trauma (chafing from his shoes) • male patient, 52 years old • progressive ulcer developed 4 months ago following an insect bite • no tendency to heal • vascular surgery: compensated circulation, no sign of trophic disorder • sampling excision from the ulcer • Diagnosis: pyoderma gangrenosum • ANA, ENA, ANCA, ASCA screen: negative • Therapy: systemic steroid sine effecto; 4 cycles of cyclophosphamide – healing excavated, deep ulcer, continuity of the Achilles tendon has broken • sampling excision from the ulcer • Diagnosis: pyoderma gangrenosum • ANA, ENA, ANCA, ASCA screen: negative • CA-15-3: (28), CA-19-9: (72,8) positive • chest CT-scan: esophageal stenosis • abdominal CT- scan: negative for tumor • patient would not undergo gastro- enterological examination • Therapy: methylprednisolone, colchicine, necrectomy, transplantation, healing ulcer with extensive necrosis and massive granulocyte reaction • Necrosis and inflammatory infiltration consisting of granulocytic fields can be found deep under the ulcer. • secondary vascular damage • necrosis of the vessel walls
  7. 7. Case 6.: ulcer associated with lichen sclerosus et atrophicus • female patient, 61 years old • skin lesions ongoing for the last 2 years • sensitive, infiltrated, haemorrhagic, partially bullous plaques, ulcerations, scars on the extensor surface of the legs • atrophic hypopigmented macules and plaques with the various sizes on the extensor surface of the arms, the chest, the abdomen, around the hip and in the genitofemoral area • sampling excision from the lesions • histological examination: hyperkeratosis, atrophic epidermis, sclerotic dermis, mild basal vacouli - zation, hypocellular subepithelial zone, below a band-like lymphoid reaction can be seen, no sign of vasculitis • Diagnosis: lichen sclerosus et atrophicus
  8. 8. Case 7.: ulcer associated with scleroderma - rheumatoid arthritis overlap syndrome • female patient, 58 years old, locomotor symptoms since 1987, polyarthritis – rheumatologic management • coxarthrosis l.u., st.p. impl. TEP coxae l.d. (2002) • bilateral plantar ulcers – osteomyelitis – amputatio dig. ped II. l.u. (2003) • ulcer without a tendency to heal on the lateral side of the right leg, spreading over the foot, since 2005 • nearly unable to walk, severe deformities and degenerative alterations of the small and large joints • ulnar deviation and flexion contracture of the fingers on the hands, ankylosis • feet: III – IV. mallet finger, hallux valgus, II. finger removed
  9. 9. angiography: no sign of arterial stenosis, early venous filling on the right leg - sign of chronic venous insufficiency • immunological management since 2003 • immunoserology: ANA screen: 69,2 U/ml, ENA screen: 10,2 U/ml, Scl-70: 26,9 U/ml, RF IgA: 47,9 U/ml, RF IgM: 275,8 IU/ml, RF IgG: 146,5 U/ml • rheumatoid arthritis; sclerodactylia; capillary microscopy (Maricq II pattern) • Diagnosis: rheumatoid arthritis – systemic sclerosis overlap syndrome • Therapy: depo steroid, non-steroid anti-inflammatory medication, chloroquine, sulfasalazine, methotrexate, leflunomide, methylprednisolone, cyclophosphamide, pentoxifylline, fentanyl; currently the underlined • Etiology of the ulcer is multifactorial: primary disease, inactivity, limb deformity, chronic venous insufficiency Histological examination: • epithelial hyperplasia, elastic fiber degeneration • chronic inflammatory cell reaction, scarification • vascular profiferation, no sign of vasculitis
  10. 10. • Results: histological examination of ulcers without a tendency to heal performed based on the clinical picture proved to be beneficial in establishing the correct diagnosis. • Histological examination of the ulcer is suggested: atypical location; atypical wound; unknown etiology; resistance to therapy; change in the clinical presentation (ulcer base and margin: hyperkeratosis, abnormal granulation, palisade-like ulcer margin). • Conclusion: The primary aim of modern wound management is determining the disease causing the ulcer, treating the condition inducing the healing disorder, namely causal therapy. In cases of chronic ulcers resistant to therapy, ulcers of rare etiologies, such as malignancies, pyoderma gangrenosum or ulcers associated with autoimmune diseases, also have to be considered during differential diagnosis. Establishing the correct diagnosis as early as possible is substantial regarding the fate of the patient, the chosen therapy, the effectiveness and cost of the treatment and the healing of the chronic wound.
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