Case Illustration (Wound Care): Unusual Form of Lower Extremity Ulceration
Dr. Warren W. McMurry, MD, FACS

Patient A.S. is a 71 year old caucasian female who was referred to the office in 3/01 for evaluation of a painful ulceration over her left lateral malleolus. Her PMH was remarkable for a history of Essential Thrombocytopenia (ES) for which she was taking hydroxyurea (Hydrea). There was no history of tobacco use or of prior vascular disease. She related a several month history of small lesions on her lower left leg which tended to begin as small pimple-like lesions and then tended to ulcerate and subsequently slowly resolve. However, the new lesion was more distal, more painful, and more persistent than those previously. The patient had developed local erythema around the punctate ulcer and there was edema of the entire foot and ankle. Findings were felt to be consistent with an infected ulcer with cellulitis. The patient was admitted to the hospital and started on IV antibiotics and local wound care. Two days later the area was surgically debrided. Pathology showed marked acute inflammation extending into deep dermal tissues and evidence of bacterial overgrowth. There were no signs of fungus, TB, or vasculitis. Postoperatively, local wound care was initiated and antibiotics continued. The patient remained in the hospital until POD #6 as much as anything for pain control.

Over next several weeks, the patient was seen on a regular basis in the office and various types of wound care tried including more debridement. Additional oral antibiotics were tried and at one point, the patient had to be readmitted to hospital and treated for dehydration related to development of clostridium colitis. During this hospitalization, consultation was made with her hematologist/oncologist requesting that she be allowed to discontinue the Hydrea and start on an alternative medication for her ES. The patient continued to be followed in the office regularly and was started on wound care with Regranex gel dressings. She began showing signs of healing and by about 2 ½ - 3 months the wound was healed and asymptomatic.

Subsequent to this case, a paper from the Annals of Internal Medicine from 1998 was discovered by the patient's oncologist (Vol.128, No.1, pp. 29-32). The paper describes experience with fourteen patients over a fifteen year period taking hydroxyurea for various conditions, who had problems with development of leg ulcerations. One of the most frequent sites of these ulcers was the malleolar area. The ulcers were recalcitrant to various treatment modalities until the hydoxurea was either discontinued or the dose lowered. A cumulative effect of the drug was implied as patients didn't develop problems for a mean of (two to fifteen years). The mechanism is unclear. around six years

The case illustrates the importance of a comprehensive approach to management of lower extremity wounds. All aspects of the patient's medical history and risk factors must be considered.