Clinico-Etiological Evaluation of Chronic Leg Ulcer in a Tertiary Care Center of Eastern India

Background:

A chronic leg ulcer (CLU) is a significant public health problem. It has various etiologies. Racial, familial, occupational, and social factors may also have an impact on the prevalence of different causes of leg ulcers. Though there are western data on the epidemiology of leg ulcer, similar data are largely unavailable from our part of the world.

Aims:

We undertook a study in a tertiary care center in eastern India to determine the clinical and etiological pattern of patients with CLU.

Materials and Methods:

Hundred consecutive patients presenting with CLU, fulfilling the criteria, were included after informed consent. Patients were subjected to proper history taking, clinical examination, routine blood test, and pus for culture and sensitivity test (where needed) along with Ankle Brachial Index (ABI).

Results:

Among the 100 patients, venous ulcer (34%) was predominant followed by arterial ulcer (14%), mixed arterial and venous ulcer (11%). History of smoking (56%) and obesity (BMI >25) (32%) were the common risk factors in leg ulcer patients. Fifty nine percent of the total CLU were infected and out of this, 86.4% showed growth of microorganisms. Staphylococcus aureus (39%) was the most commonly isolated organism, followed by Pseudomonas aeruginosa (15%). Eleven (24.44%) clinically diagnosed venous ulcer patients showed significantly lower ABI (<0.9) and were diagnosed as mixed ulcer (a venous ulcer with a peripheral arterial disease).

Conclusion:

Venous ulcer and mixed ulcer are the most common type of CLU.

Clinicopathological and Immunological Profile of Patients with Cutaneous Manifestations and their Relationship with Organ Involvement in Systemic Lupus Erythematosus Attending a Tertiary Care Center of Eastern India

BACKGROUND

Lupus erythematosus (LE) is an autoimmune disorder with diverse clinical manifestations ranging from mild cutaneous disorder to life-threatening systemic illness and associated with varying immunological parameters.

AIM

We conducted a study in a tertiary care center of eastern India to determine the clinical pattern, immunological profile of patients with cutaneous manifestations of systemic LE (SLE) and their relationship with organ involvement.

MATERIALS AND METHODS

Fifty-five consecutive patients attending dermatology OPD having features consistent with cutaneous LE and fulfilling the criteria of SLE were included. After proper history taking and clinical examination, routine blood and antinuclear antibody (ANA) profile, histopathological examination, and direct immunofluorescence test were undertaken.

RESULTS

Among 55 patients, 49 were female. ANA positivity was the most common association, followed by photosensitivity, malar rash, arthritis, oral ulcer, immunological markers, renal system involvement, discoid rash, serositis, central nervous system (CNS) involvement, and least common being the hematological involvement. Vacuolar basal cell degeneration was the commonest epidermal change and upper dermal periappendageal and perivascular lymphocytic infiltration was the commonest dermal change observed on histopathological examination. On direct immunofluorescence (DIF) granular pattern was seen in majority of patients. Statistically significant risk of kidney involvement was present both when patient had bullous lesions and DIF positivity of unexposed (DIF-UE) skin. CNS involvement was seen in five patients and it was found to be significantly associated with purpuric lesions.

CONCLUSION

This study reveals cutaneous lesions and DIF testing could be reliable predictors of systemic involvement and strongly suggests DIF testing, routinely in all patients of SLE.

A case of ichthyosis hystrix: unusual manifestation of this rare disease

Ichthyosis hystrix is a term used to describe an ichthyosiform dermatosis which is characterized by hyperkeratotic spiny scales mainly over extensor aspects of limbs with palmoplantar keratoderma and occasionally associated with deafness and neurological deficit. It is a rare autosomal dominant form of ichthyosis and very few cases are reported in literature. We are presenting a 46 years-old-male patient of ichthyosis hystrix with unusual presentation. He had lesions mainly over the face and scalp with palmoplantar keratoderma and significant nail changes.

A curious case of sweating blood

Hematohidrosis is a very rare condition in which an individual sweats blood. It may occur in an individual who is suffering from extreme levels of stress. Various causative factors have been suggested like component of systemic disease, vicarious menstruation, excessive exertion, psychogenic, and unknown causes. Fear and intense mental contemplation are the most frequent causes. It may also occur in bleeding disorders. We here report a case where bloody sweat was discharged from the forehead, face, and body episodically in a 12-year-old healthy girl with no bleeding disorder or any other underlying cause. All investigations done were within normal limits, except low intelligent quotient and loss of insight. The patient was given atropine sulphate transdermal patch with marked improvement in severity.

Ichthyosiform large plaque parapsoriasis: report of a rare entity

Large plaque parapsoriasis (LPP) is an idiopathic, chronic scaly dermatosis classified within parapsoriasis group of diseases, occurring commonly in middle aged patients of all races and geographic regions. LPP and its variants are closely related to the patch stage of mycosis fungoides. The two types of LPP mostly described are the poikilodermatous and retiform parapsoriasis. We are reporting an ichthyosiform LPP for its rarity.

Chronic venous ulceration of leg associated with peripheral arterial disease: an underappreciated entity in developing country

Chronic venous ulcer can often be associated with asymptomatic peripheral arterial disease (PAD), which usually remains undiagnosed adding significantly to the morbidity of these patients. The Ankle-Brachial Pressure Index (ABPI) is suggested for PAD evaluation. Many PAD studies were conducted in western countries, but there is a scarcity of data on the prevalence of PAD in clinical venous ulcer patient in developing countries. We conducted a study in a tertiary care hospital of eastern part of India to find out the prevalence of PAD in venous ulcer patients, and also to find the sensitivity of ABPI as a diagnostic tool in these patients. We evaluated clinically diagnosed patients with venous ulcer using ABPI and Colour Doppler study for the presence of PAD. Possible associations such as age, sex, body mass index (BMI), smoking, hypertension and atherosclerosis were studied. All results were analysed using the software Statistica version 6. PAD was present in 23 (27·71%) patients. Older age, longer duration, smoking, high BMI and hypertension were found to be significantly associated with PAD. A very strong level of agreement was found between venous Doppler and ABPI. Assessment for the presence of PAD is important in all clinically diagnosed venous ulcer patients. ABPI being a simple, non-invasive outpatient department (OPD)-based procedure, can be routinely used in cases of venous ulcer to find out the hidden cases of PAD even in developing countries.

Non healing leg ulcer infected with Stenotrophomonas maltophilia: first reported case from India

Stenotrophomonas maltophilia is a recently described organism which was mainly reported either in nosocomial setup, or in immunosuppresed individuals. This was rarely reported as cutaneous pathogenic organism causing cellulitis-like lesion, paronychia, mucocutaneous ulcers and ecthyma gangrenosum in immunocompromised individuals. Here we describe a case of leg ulcer caused by S. maltophilia in an immuno-competent patient. The infection was possibly community acquired as the patient had no exposure to hospital environment. The bacillus was sensitive to cotrimoxazole and levofloxacin, and the patient was successfully treated with cotrimoxazole. Our case is unique not only because it is probably the first ever case of leg ulcer caused by S. maltophilia, but also because of its unusual occurrence in immunocompetent patient.