65-Year-Old Woman With Painful Leg Ulcers

Abstract

65-year-old woman presented to Mayo Clinic, Roch- ester, Minn, for a second opinion concerning chronic,nonhealing lower extremity ulcers. Eighteen months beforepresentation, she spontaneously developed a moderatelypainful ulcer on her right lateral calf. This ulcer was treatedwith multiple topical therapies including collagenase, regu-lar dressing changes (DuoDERM), bacitracin, and com-pression garments (Jobst) with no improvement. The rightlower extremity ulcer was then debrided surgically, whichseemed to make it worse. Twelve months before presenta-tion at Mayo Clinic, the patient developed a similar butmore painful ulcer on her left lateral calf. This ulcer, too,was resistant to topical treatment. Although laboratory re-sults for vasculitis had been normal, she was given anempirical course of oral prednisone for possible vasculiticetiology without improvement. Surgical debridement wasagain recommended, but the patient refused and presentedto Mayo Clinic for a second opinion.The patient had no history of lower extremity ulcers,prior deep venous thrombosis, or claudication. She used notobacco products, and there was no evidence of diabetesfrom previous or current laboratory evaluation. Her medi-cal history was remarkable for poorly controlled hyperten-sion. The patient’s medications included alpha methyl-dopa, 250 mg 3 times daily; potassium, 10 mEq twicedaily; furosemide, 20 mg twice daily; indomethacin, 25 mg3 times daily; and glucosamine chondroitin, twice daily.Examination of the patient revealed that her blood pres-sure level was 180/90 mm Hg. Findings on the rest of herexamination were unremarkable except for her lower ex-tremities. Dorsalis pedis and posterior tibial pulses wereeasily palpable bilaterally. Edema was minimal. The pa-tient had bilateral ulcers (0.5 × 1.5 cm on the right and 2.5 ×3.0 cm on the left). Both ulcers had a surrounding zone oferythema with sharply demarcated borders and minimalgranulation tissue. No evidence of purulent discharge orinfectious odor was associated with the ulcers. The ulcers