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A 71-year-old woman had an ulcer
of the lateral left leg and ankle. She was treated
for 4 years for "venous ulceration", but
multifocal lytic ulceration, exposure but sparing
of muscles and tendons, distribution along tendon
sheaths, absence of venous pigment and edema, and
various musculoskeletal symptoms are all paradigm
features of rheumatoid and similar immunopathic
wounds.
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After making and confirming the
diagnosis of rheumatoid arthritis, anti-inflammatory
and anti-metabolic treatments were started. The
wound was excised and closed with Integra, including
coverage of bare fibular cortex and multiple muscles
and tendons.
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The involved area healed quickly
and has remained healed ever since, seen here at
6 months.
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Two years later, the patient
became very ill with disease flare-up. Rheumatoid
panniculitis and multifocal ulceration occurred
on both lower extremities, seen here on the medial
side of the left leg. Topical wound care, compression
and edema control, intralesional steroids, and increased
systemic therapy brought the acute problems under
control, but left multiple open wounds.
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This image is simultaneous
to the previous. Whatever else has happened nearby,
the original lateral leg reconstruction remained
healthy throughout the acute flare-up.
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The new ulcers on the medial
side of the leg did not heal after a suitable
period of topical care and observation. Integra
was then used, and all healed, seen here 9 months
later.
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Cases Courtesy of:
Marc E. Gottlieb, M.D., Jennifer Furman
Journal of Burns and Wounds, Vol 3, #2
