Bilateral Lower Leg Research Articles

Improvement of Pretibial Myxedema Following Administration of Teprotumumab

Pretibial myxedema (PTM) is a rare complication of Graves' disease. It is characterized by non-pitting edema with hyperpigmented hyperkeratotic papules and plaques on bilateral lower legs. Effective treatments for patients with PTM are lacking. The etiology of PTM is unknown; however, it may be similar to the mechanism of thyroid-associated ophthalmopathy (TAO). Activated fibroblasts produce inflammatory cytokines and synthesize excessive glycosaminoglycans (GAG) that accumulate in the dermis and subcutaneous tissue. A recent, novel pathway implicates IGF-1 receptor as a mediator in this process. We present two patients with refractory PTM that improved following treatment with teprotumumab, an IGF-1 receptor inhibitor approved for use in TAO. J Drugs Dermatol. 2022;21(11):1252-1254. doi:10.36849/JDD.6854.

Pembrolizumab-induced rash in a patient with angiosarcoma

A 78-year-old male with angiosarcoma of the scalp developed a pruritic rash 14 months after initiating pembrolizumab therapy. Examination revealed pink papules coalescing into plaques involving the back, chest, bilateral arms, and thighs (Fig 1, A). On the bilateral lower legs, there were multiple 1-2 cm well-circumscribed ulcers and few intact bullae (Fig 1, B).

Major intraoperative bleeding and drastic change in circulatory dynamics in a pregnant patient with metastatic pheochromocytoma: a case report

BackgroundMetastatic pheochromocytoma in the spine is a very rare complication during pregnancy. We report anesthesia in a pregnant woman for resection of an undiagnosed spinal tumor, accompanied by remarkable hemodynamic changes and massive bleeding.Case presentationA 33-year-old woman at 17 weeks of gestation presented with the rapid progress of bilateral lower leg paralysis. A diagnosis of spinal tumor was made, and surgical resection was planned. Although the surgery was suspended because of remarkable hemodynamic changes and massive bleeding, fetal heart rate was stable. Postoperative examination revealed pheochromocytoma in the urinary bladder as a primary lesion with spinal metastasis.ConclusionAlthough spinal pheochromocytoma is extremely rare in pregnant women, it should be suspected when abnormal hypertension is observed with accompanying neurological deficits. Preservation of maternal circulation and uteroplacental blood flow should be the first priority during anesthesia.

Primary malignant multiple osteogenic sarcomas: a rare clinical image.

We present the case of a 12-year- old male patient, who came to the emergency department with a complaint of pain in bilateral knee joints, pain in bilateral lower legs, multiple swelling over the bilateral knee joint and in the leg region, difficulty in walking, stiffness in the bilateral knee joint since he was one year. There is no medical significant history regarding the disease condition. On physical examination, the swelling was in the region of the metaphysic of the distal end of the bilateral femur and proximal end of the bilateral tibia, skin over the swelling was shiny with tenderness and margins were irregular, on the biopsy and X-ray findings patient was diagnosed as primary malignant multiple osteogenic sarcomas. The patient was referred to the dermatology department for further management.

25894 CLL-associated cryofibrinogenemia

Cryofibrinogenemia is an occlusive vasculopathy characterized by cold precipitation of cryofibrinogens (CF), which may be idiopathic or secondary to malignancy, infection, or systemic inflammatory disease. Here, we present the case of a 75-year-old woman with a 1-year history of untreated chronic lymphocytic leukemia (CLL) and a new retiform purpuric eruption of the lower extremities, present for 1 month. On presentation, the patient was noted to have palpable purpuric papules and retiform purpuric patches, some of which were ulcerated centrally, on the bilateral lower legs.

Edematous lower extremities with overlying verrucous plaques

A 45-year-old African American man with a past medical history of Graves disease (GD) presented to the dermatology clinic for evaluation of a 10-year history of painful lesions on his bilateral lower legs. The patient reported symptoms of lower extremity edema, which worsened by prolonged standing. Treatments included compression stockings without improvement. A physical exam demonstrated firm, non-pitting edema and hyperpigmentation of his bilateral lower legs with many verrucous papules and plaques (Fig 1).

The Canadian Dermatology Association’s Top Five Choosing Wisely Canada Recommendations

In this article, we present the Canadian Dermatology Association's (CDA) Choosing Wisely Canada (CWC) list of top "Five Things Physicians and Patients Should Question in Dermatology" and the evidence in support of each recommendation. Using a nominal technique, the CDA Working Group and Task Force generated an initial list based on literature review and expert consultation. After several rounds of list refinement via a modified Delphi process, a final list of recommendations was generated. These were approved by the CDA Board of Directors, presented at the CDA 93rd Annual Conference in 2018, and published by CWC in 2019. The top five recommendations are as follows: (1) Don't routinely prescribe antibiotics for bilateral lower leg redness and swelling; (2) Don't routinely prescribe topical combination corticosteroid/antifungal products; (3) Don't routinely use topical antibiotics on a surgical wound; (4) Don't prescribe systemic antifungals without mycological confirmation of dermatophyte infection; and (5) Don't use oral antibiotics for acne vulgaris for more than 3 months without assessing efficacy. This list of recommendations aims to encourage both physicians and patients to reevaluate ineffective, yet common, practices in treating dermatologic conditions. These recommendations represent actionable changes in practice, and therefore have considerable potential to enhance value-based care in dermatology. This list was developed to identify tangible changes in practice within dermatology that may reduce inefficiencies, prevent potential patient harm, and improve care. Future advocacy work may include updates, feedback obtainment, and patient care handouts, to continue to promote value-based healthcare and best practices.

Pathological complete response after afatinib treatment of stage IV oligometastatic adenocarcinoma of the lung: the role of pulmonary surgery

BackgroundSome oligometastatic lung cancer patients, after induction systemic chemotherapy or tyrosine kinases inhibitor treatment, followed by aggressive radical consolidative treatment, have improved overall survival. Unfortunately, clinical criteria cannot assess such patients.Case presentationWe hereby reported the case of a 55-year-old female with lower back pain and bilateral lower leg numbness for months and who had an osteolytic bone lesion over the third lumbar vertebra. In February 2017, a third lumbar vertebra biopsy showed metastatic adenocarcinoma, compatible with lung origin (thyroid transcription factor-1 positive [TTF-1], L858R mutation positive). Complete imaging of the right lower lobe (RLL) showed a spiculated mass of about 3.4 × 2.2 cm, and a trans-bronchoscopic lung biopsy revealed non-small cell carcinoma of lung origin (positive for TTF-1 and negative for p40). Tentative diagnosis was RLL adenocarcinoma, cT2aN0M1b, with bone metastasis at L3. The epidermal growth factor receptor-tyrosine kinase inhibitor afatinib was prescribed beginning April 2017. A November 2018 follow-up CT scan showed regression in the RLL lung mass. A whole-body positron emission tomography-computed tomography showed RLL lung nodule with faint uptake and mildly increased uptake in the L3 vertebra. After providing informed consent, the patient received uniportal video-assisted thoracoscopic RLL lobectomy and radical mediastinal lymph node dissection on December 25, 2018. The final pathology report was fibrotic scar with no residual tumor cells, compatible with post-treatment status, ypT0N0. Curative intent radiotherapy was also applied to the L3 vertebra after the operation. The patient is still alive for more than 32 months after initially diagnosed with metastatic lung adenocarcinoma.ConclusionsOur case provides additional data to support that tissue assessment through primary lung tumor resection after systemic treatment of oligometastic lung cancer by minimally invasive surgery can reveal the treatment effect and potentially provide a surrogate endpoint in further clinical trials.

Management of Chronic Kidney Disease (Mutraghata) through Ayurveda regimen: A Case Report

Chronic Kidney Disease (CKD), prevalence is 17.2% with stage 1, 2, 3, 4, 5 as 7%, 4.3%, 4.3%, 0.8% and 0.8% respectively, 43.1% of their cohort had hypertension and 18.8% had diabetes. It is a global threat to health in general and for developing countries in particular because in modern science, therapy is expensive and lifelong. In India, 90% patients cannot afford the cost. Ayurveda can help in such conditions. A 55-year-old male patient of Chronic Kidney Disease with chief complaints of swelling in bilateral lower leg, constipation and he was on dialysis (three times in a week). He was known case of Hypertension in the last 15 years. On examination, this manifestation was diagnosed as 1Mutraghat. Considering the case, different Panchakarma procedures including Snehana, Avagahana swedana and Virechana, Kala Basti were adopted along with other internal medicines. Assessments were made using laboratory examinations and symptoms. At the end of the treatment, there was considerable improvement in the subjective and objective clinical features. The observations reveal that, internal medicines can play a key role in the management of chronic kidney disease. The treatment strategies followed in this study can be safely adopted under the supervision of competent specialist.

Polyarteritis nodosa with ureteric stenosis

AbstractPolyarteritis nodosa (PAN) is a primary systemic medium‐vessel vasculitides. In systemic PAN, the most frequent skin lesions are purpura, livedo, and nodules. We report a case of PAN with stenosis of the ureter. A 60‐year‐old Japanese woman had a 5‐year history of subcutaneous nodules, purpura, livedo‐like dark erythema on the bilateral lower legs, with histopathology of necrotizing vasculitis of medium‐sized arteries. Radiologically, hydronephrosis of both kidneys was found with stenosis of the ureters. She received radical nephrectomy of the right kidney and ureter and retention of ureteral stent for the left one. The removed ureter showed stenosis with prominent fibrosis of the lamina propria and muscular layer. We diagnosed the condition as systemic PAN with ureteric stenosis. Oral prednisolone exerted a good therapeutic effect. There have been reported 16 cases of systemic PAN with ureteric stenosis, including our case. Ureteric stenosis is one of the important manifestations of systemic PAN.

Characteristics of lower leg and foot muscle thicknesses in sprinters: Does greater foot muscles contribute to sprint performance?

The present study aimed to determine the differences in thicknesses of the lower leg and foot muscles between sprinters and non-sprinters and to examine the relationship between these muscle thicknesses and sprint performance in sprinters. Twenty-six well-trained sprinters and 26 body size-matched non-sprinters participated in this study. Total 9 muscle thicknesses of bilateral lower leg and foot muscles in participants were measured using ultrasonography. Regarding the lower leg muscles, thicknesses of the tibialis anterior, gastrocnemius medial, and gastrocnemius lateral were measured. Regarding the foot muscles, thicknesses of the flexor digitorum longus, flexor hallucis longus, peroneal longus and brevis, abductor hallucis, flexor digitorum brevis, and flexor hallucis brevis were measured. Most muscle thicknesses were significantly larger in sprinters than in non-sprinters. The differences in mean thicknesses of both legs between the two groups were greater in the foot muscles, where it ranged from 10.2% to 17.1%, than in the lower leg muscles, where it ranged from −0.9% to 9.4%. Among foot muscles, the thickness of only the abductor hallucis was positively correlated with the personal best 100-m sprint time in sprinters (r = 0.419, P = 0.033), indicating that a greater abductor hallucis may be a negative factor for superior sprint performance. These findings suggest that although the foot muscles in addition to the lower leg muscles are more developed in sprinters than in non-sprinters, these muscle sizes may not contribute to achieve superior sprint performance.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P63. Pain-related safety outcomes seven years following lumbar total disc replacement in mobile core devices versus constrained core devices

BACKGROUND CONTEXT Total disc replacement (TDR) is an alterative to fusion for treating patients with disabling discogenic back pain. While several studies report significant improvements in overall back pain following TDR, some patients may experience recurring episodes of pain in the lumbar and/or lower extremities. Competing lumbar disc arthroplasty devices include a mobile core device versus a constrained core device. Long-term follow up (>7 years) from investigational device trials is now available to better assess long-term outcomes with arthroplasty with the two device types. PURPOSE To evaluate pain-related adverse events in patients 7years following single-level total disc replacement at L4–L5 or L5–S1 with either a mobile core disc (MCD) or a constrained core device (CCD) to determine if implant design is associated with increased pain serious adverse effects at 7-year follow-up. STUDY DESIGN/SETTING This post-hoc analysis of a multicenter, prospective, randomized, controlled, investigational device exemption trial included patients with symptomatic lumbar degenerative disc disease at L4–L5 or L5–S1. PATIENT SAMPLE The patients had lumbar arthroplasty surgery with either an MCD (n=218) or CCD (n=65) implant and were randomized prior to surgery in the IDE study. OUTCOME MEASURES The study reviewed events deemed to be serious adverse events in a FDA IDE study. METHODS This post-hoc analysis of a multicenter, prospective, randomized, controlled, investigational device exemption trial included patients with symptomatic lumbar degenerative disc disease at L4–L5 or L5–S1. Pain related adverse events (AE) at 7years post implantation for TDRs as a class and by device type (MCD vs. CCD) are reported. RESULTS Of the reported AEs, 23% (N=327) were categorized as pain of the lumbar and/or lower extremities: lumbar only (7%), lumbar and bilateral lower leg (5%), and lumbar and unilateral lower leg (3%). Patients presenting with AEs reported an average of two pain related AEs at 7years post-op. Of the pain related AEs, 11% were device related, 8% were procedure related and 9% were serious AEs (SAEs). Onset of the first pain related SAE occurred on average at 49days (range: 0–118 days) and 395days (range: 0–2,728 days) following CCD and MCD implantation, respectively (p=.21). Overall, the majority of pain related SAEs were classified as severe (69%). A greater proportion of patients implanted with the CCD device presented with severe SAEs (88%) compared to patients with MCD (61%; p=.17). At the 7-year follow-up, over half of the SAEs occurring in MCD patients were resolved (56%) while the SAEs in CCD patients remained mostly unresolved (75%; p=.14). CONCLUSIONS While the rate of pain related AEs were the same between patients implanted with an MCD or CCD implant, there were observed differences in the quality of SAEs between the two TDR devices. On average, the first pain related SAE in MCD patients occurred approximately 1 year after CCD patients. Furthermore, a smaller proportion of SAEs were severe and a greater proportion was resolved by the 7-year follow-up appointment with MCD versus CCD implanted patients.

Disseminated cryptococcosis presenting initially as lower limb cellulitis in a renal transplant recipient \u2013 a case report

BackgroundCellulitis is an unusual presentation of disseminated cryptococcosis, a serious infection seen predominantly in immunocompromised hosts. Disseminated cryptococcosis carries significant morbidity for transplant recipients, especially of the pulmonary and central nervous systems, and carries a high mortality risk.Case presentationWe report a 59-year-old renal transplant recipient who presented with bilateral lower leg cellulitis without other symptoms or signs. Failure of conventional therapy for cellulitis prompted a skin biopsy confirming cryptococcal cellulitis. Additional evaluation to exclude disseminated disease revealed Cryptococcus neoformans in blood cultures and cerebrospinal fluid (CSF). Treatment included reduction in immunosuppression regimen and targeted treatment for cryptococcal disease with liposomal amphotericin B and flucytosine followed by fluconazole consolidation and maintenance therapy. Treatment with liposomal amphotericin B and flucytosine followed by fluconazole consolidation and maintenance therapy achieved a good clinical response. Our patient achieved significant reduction in leg cellulitis and recovered without serious complication.ConclusionsThis case suggests that cutaneous cryptococcosis in immunosuppressed patients warrants a low threshold for investigation for disseminated disease even in the absence of other symptoms or signs.

Treatment in the home setting with intermittent pneumatic compression for a woman with chronic leg ulcers: a case report

BackgroundIntermittent Pneumatic Compression (IPC) is shown to improve the healing rate of Venous Leg Ulcers (VLU) in the hospital setting. The current Australian “Gold Standard” treatment according to the Australian and New Zealand Wound Management Associations’ (AWMA) Prevention & Management of Venous Leg Ulcer guidelines is compression, generally in the form of bandaging then progressing to hosiery once wounds are healed to prevent recurrence. This is recommended in conjunction with other standards of wound management including; nutrition, exercise, client education and addressing underlying pathophysiology and psychosocial factors. Compression bandaging is predominantly attended by community nurses in the clients’ home. Barriers to delivery of this treatment include; client concordance and or suitability for bandaging including client habitus, (shape of legs), client lifestyle, clinician knowledge and clinicians physical ability to attend bandaging, in particular for obese clients with limited mobility who pose a manual handling risk to the clinician themselves. The use of IPC may assist in mitigating some of these concerns, therefore it would seem wise to explore the use of IPC within the home setting.Case presentationThis paper will present an original case report on the successful treatment of a woman living with chronic bilateral lower leg ulcers using IPC as an adjunct treatment in her home. This paper supports recommendations to explore the use of IPC therapy in the home setting, for treatment of chronic leg ulcers requiring compression.ConclusionUse of IPC in the home is anticipated to improve client involvement, concordance, client outcomes and reduce risk to staff applying conventional compression bandaging systems, particularly for obese clients with limited mobility.

Intradural-Extramedullary Metastatic Tumor from Lung Cancer-A Case Report and Review

A 62-year-old male presented with a thoracic intradural-extramedullary metastasis from lung cancer. He complained of walking difficulty and bilateral lower leg numbness. He had a past history of lung adenocarcinoma three years prior. Thoracic spine magnetic resonance imaging showed that the tumor occupied the right subarachnoid space and spinal nerve roots had shifted to the left side at Th12. He was diagnosed with cauda equina syndrome by an intradural-extramedullary tumor. Surgery was performed (Th12 laminectomy) and we opened the dura mater and arachnoid membrane. The tumor was in the right side and was removed. After the operation, his neurological condition soon improved and he could walk with a cane. By four moths postoperatively, a metastatic brain tumor occurred and he had to use a wheel chair. He died one year after surgery. Immunohistochemical staining was positive for thyroid transcription factor-1 in both the lung adenocarcinoma and intradural-extramedullary tumor. We diagnosed a metastatic tumor. Including the present case, 102 cases of a metastatic intradural-extramedullary tumor have been reported and, thus, the condition may not be rare. In more than twenty years there have only been two case studies, which recommended both operative and non-operative methods. We reviewed the validity of an operation base on the prognosis and surgical results of previous reports. The average life expectancy was 8.6 months. The functional improvement rate was 78%. We recommend an operation for an intradural-extramedullary metastatic tumor because it improves the quality of a patients’ short life.

Repair of soft tissue defects in lower extremities by latissimus dorsi myocutaneous flap with T type of vascular pedicle

To investigate the Application of latissimus dorsi myocutaneous flap with T type of vascular pedicle in repairing soft tissue defects at lower extremities. Between January 2003 and August 2013,16 patients with skin and soft tissue defects at lower extremities were treated with T type vascular pedicled latissimus dorsi myocutaneous flap through bridge transplantation. There were 13 male and 3 female patients with an average age of 36.2 years(range,17-54 years).Skin and soft tissue defects in the lower extremities ranged from 18 cm × 13 cm to 32 cm × 15 cm. The T-configuration vascular anastomosis was formed by anastomosing the subscapular and circumflex scapular vessels to the proximal and distal ends of the posterior tibial vessel broken in the normal leg respectively in an end-to-end manner. The latissimus dorsi myocutaneous flap was used to cover the defect at damaged leg where vascular pedicle was wrapped by tube flap from the normal leg. External fixators was used to immobilize the bilateral lower legs postoperatively. Vascular crisis occurred in 3 cases. Vascular crisis was relieved after exploring the vessel.2 cases developed infection at the distal end of flap and cured by debridement. Primary healing was obtained in 11 cases after 2 weeks,and the total survival rate was 100％.The follow-up period lasted for 6 months to 5 years with an average of 3.4 years. The flap appearance was satisfactory and extremity function was restored to normal. The application of the T type of vascular pedicled latissimus dorsi myocutaneous flap by bridge transplantation is an effective method for repair skin and soft tissue defects in lower extremity without damaging for main blood vessels at contralateral limb, when affected extremities have no available vessel for anastomosis.

Once-nightly (QD) dual CYP17-Lyase (L) inhibitor / androgen receptor (AR) antagonist VT-464 in patients with CRPC.

343 Background: VT-464 is an oral, CYP17-L inhibitor and non-clinically an antagonist of the AR and its variants associated with clinical resistance to enzalutamide (ENZ) and abiraterone (AA). The safety, tolerability and initial PD effects (tumor responses, PSA and testosterone (T)-decreases) of QD VT-464 were evaluated in this Phase (Ph) 1/2 study (INO-VT-464-CL-004; NCT02361086). Methods: Chemotherapy-naïve (n = 20) M0 (n = 1) and M1 (n = 19) patients with CRPC prior to (TN, treatment-naïve; n = 9), or after AA (n = 6),ENZ (n = 3) or both (n = 2) were enrolled in sequential dose-cohorts of 600 mg QD with dose titration (DT; 300 mg QD q2w), and 600 and 750 mg QD without DT in 28-day continuous dosing cycles. All doses except the first were given at night with dinner. Patient results through the 750 mg QD cohort are reported (data cut off 17 Aug 2015). Results: Patients received VT-464 without steroids at 600 mg QD+DT (n = 3), 600 mg QD (n = 8) or 750 mg QD (n = 9). Eight patients are on study in cycles 3-12. Most adverse events (AEs) were Grade (Gr) 1 or 2. Fourteen Gr 3 AEs were reported with 7 considered unrelated and 7 ≥ possibly related; 5 of the latter were in the 600 mg QD+DT cohort (bradycardia, hypotension, syncope, hypertension and hyponatremia) with 2 in non-DT cohorts (hypotension, bilateral lower leg weakness). No AEs ≥ Gr 4 were reported. One DLT occurred in the 600 mg QD+DT cohort (syncope). No mineralocorticoid excess syndrome, ACTH response changes, or increased LFTs were observed. Plasma T was below the LOQ (0.03nM) in 67% of patients, with progesterone and cortisol unchanged. Cmax was similar in all cohorts to 450 mg bid (de Bono et al, GU ASCO 2015) but AUC was decreased. All 4 TN patients had PSA declines at 600 mg QD including one 30% and one 50% response; there was one 50% response in the 600 mg QD+DT cohort. Both TN patients treated at 750 mg QD had > 50% response. Of 8 patients with ≥ 1 soft tissue target lesion and ≥ 1 post-baseline scan, 5 had stable disease and 1 had a partial response at Cycle 5. Conclusions: The VT-464 750 mg QD regimen demonstrated potent and selective CYP17 L inhibition and has been selected for all Ph 2 clinical studies based upon improved tolerability, PK and efficacy compared to bid+DT dosing (de Bono et al, GU ASCO 2015). Clinical trial information: NCT02361086.

Dopamine Gangrene on the Bilateral Lower Legs: A Case Report and Review of the Literature

Dopamine Gangrene on the Bilateral Lower Legs: A Case Report and Review of the Literature

Recurrent bilateral lower leg ulcers in an adult patient: A case report

Recurrent bilateral lower leg ulcers in an adult patient: A case report

Exercise-related leg pain and risk factors in inter university distance runners

Context: Understanding the concept of prevalence and risk factors of exercise-related leg pain (ERLP) in distance runners. Aims: To find out the prevalence and in the seasonal incidence of ERLP in inter university distance runners. To investigate risk factors for developing ERLP. Settings and Design: The present cross-sectional study conducted at the track and field in Guru Nanak Dev University and other universities in Punjab. Materials and Methods: A total 70 athletes (40 male, 30 female) were participated voluntarily. Precompetitive demographic, basic anthropometric, training parameters and ERLP history data were collected from the initial questionnaire. Foot type and plantar flexor endurance were measured from each individual using navicular drop test, standard heel raise test, and runners were tracked throughout the session to note the percentage of in seasonal ERLP. Statistical Analysis Used: Chi-square and odds ratio was applied to find out the risk factors of ERLP. Results: Overall 48.57% male and 37.14% female athletes had a history of ERLP and 14.2% athletes did not have any history of ERLP out of 70 athletes. Among them 81.4% (57) athletes completed postseasonal questionnaire, out of 57 athlete's 42.1% (24) male and 28% (16) female athletes developed in seasonal ERLP, bilateral lower leg pain was the most common presentation. There was a significant difference seen between ERLP history (1-month) and body mass index (BMI) within seasonal ERLP (P < 0.02), (P < 0.04), as compared to 6 and 12 month history of ERLP. Conclusions: The results of the present study conclude that BMI and ERLP history (1-month) was the only risk factor for in the seasonal development of ERLP in distance runners.