Return of the painful leg ulcers

Abstract

A31-year-old man who worked as a landscape gardener was seen because of painful ulcers on his left lower leg that had been recurrent for 3 years. His history included multiple episodes of bilateral deep venous thrombosis in his upper and lower extremities and two episodes of pulmonary embolism during the previous 6 years. His father had a history of recurrent deep venous thrombosis, cerebrovascular accident at the age of 47 years, and seropositivity for lupus anticoagulant. On physical examination, several painful ulcers ranging in diameter from a few millimeters to 2 cm were seen on his left lower leg. A purplish area of livedo over the left fifth toe and scars from previous ulcers also were noted. Laboratory results included: platelets 118×10 3 /μL, a negative antinuclear antibody screen, and a positive antiphospholipid antibody test (138 IgG phospholipid [GPL] units [normal, <15 GPL units]). Factor V Leiden, cryofibrinogen, and cryoglobulin were not detected. A duplex ultrasound scan showed residual deep venous thrombosis extending from the left popliteal vein down through the left peroneal veins. Biopsy of tissue from the left lateral calf revealed a superficial and deep perivascular lymphocytic infiltrate and scattered eosinophils and fibrin thrombi in the deep dermal vessels.