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an 80 year old female, who has advanced dibetes with blindness, gastric paresis and renal failure on dialysis complained of ulcers on her lower extermeties for the last few weeks. they were on the knees, legs and feet. some were painful. on examination she had multiple shallow ulcers of varying sizes, with sorrounding erythema. it was covered by a thick adherent yelloish crust which later (1 week) became necrotic.
her differential initialy was between calciphylaxis, pyoderma gangrenosum or infection.
her dobbler showed obstruction of the posterior tibial artery. she also had high fibrinogin level.
a biopsy was taken which showed fibrin deposition in the blood vessels. no calcium deposits.
we believe that what she has is related to her dibateic vascolpathy. she was started on pentoxifyllin and improved slightly ever since. her coagulation profile is under investigation too.
are we dealing with a vascular problem or coagulapthy?
Filed under: Uncategorized | Tagged: diabetes
dermlive
dermis111
dr660
skindr
visitor111
epiderma
kamalsaleh
I think this case have both vasculaer and coagulapthy at the same time.
for treatment of ulceration the patient need frequent wound excision with local treatment by proacutase spray and skin gel (ionic hydrogel)t.d.s,we should correct hydration of the patient with good control of blood suger,the patient my need heamatologist to deal with coagulapathy,slso protection from pressur sores by using air bed
The vasculopathy explains the acral skin involvement but not the one on the knee, so propably a deep skin biopsy involving the fat tissue should be done to exclude tachyphylaxis and if negative autoimmune ( antiphospholipids ) and coagulopathy investigations ( factor C ,S and 3) should be done.
it can be explained by both mechanisms but vasculopathy is the expected to be the reason in this case.. it has to be managed for both pathological mechanisms and pt home circumstances like immobility and immunity state