Case 78: Treatment of Stasis Ulcers in Patient with Chronic Lymphatic Leukemia, Diabetes and Mental Retardation

At age 65, this 7th grade graduate presented December 4th, 1992 with stasis ulcers on both legs. He had had varicose veins stripped 18 years earlier. He recalled traumatizing his legs in October when he first visited his physician. The local measures and antibiotics prescribed by the latter had provided no benefit. He was a two pack a day smoker of many years duration. He appeared to have adequate arterial flow; while his lesions made palpation of his posterior tibial arteries difficult, both dorsalis pedis arteries were palpable.

His legs on presentation were wrapped in gauze wetted with Sea Soaks containing gentamicin and pumped in Long-Boots.

After the treatment, much of the crusting was easily brushed off revealing the true extent of his lesions beneath the crusts. December 4th, 1992.

Local measures and boot therapy were begun and basic laboratory studies obtained. A hemoglobin under 4.5gm/dl led to his hospitalization where a hemolytic anemia associated with chronic lymphatic leukemia was diagnosed. His admission fasting blood glucose was 165mg/dl documenting the presence of a previously unappreciated diabetes problem. His new medications included prednisone, cytotoxan, folic acid, allopurinol and insulin. Unable to handle the care of his lesions or the administration of his medications and unable to drive, he was transferred for long term care to our boot-nursing facility. His legs did well but his vertebral spine did not: he suffered multiple compression fractures. Once his legs were healed and his back stable, he was discharged home where it was recognized that his inactivity and quiet sitting in his wheelchair would make him susceptible to new leg lesions.

Little progress was seen at the height of his chemotherapy. March 25th, 1993.

His legs eventually healed nicely as shown here prior to going home, December 1st, 1993.

Comments: At home his lesions did recur and he found it difficult to get to the office for booster treatments. Like previous patient, regular maintenance treatments might have prevented his relapse and made it easier for him walk and make his appointments. Again maintenance treatments are against Medicare regulations. In the case of this man, some relatives arrived on the scene who had closer blood ties to him than his niece who had been orchestrating his care. They took him to a surgeon at another institution where he was hospitalized and eventually committed to a nursing home for permanent care.
His chemotherapy is a point of interest. Here we were trying to reduce his white count and eliminate the antibodies responsible for his hemolysis. The therapy likely contributed to his compression fractures and slowed wound healing.
It may be noted that especially on his right lateral leg he did not have much stasis pigmentation. When more extensive disease is present than might be expected by the presenting diagnosis (here stasis disease), it is not uncommon to find an associated underlying systemic disease or dermatological disorder. Booting helps stasis patients but will not help neoplastic skin infiltrates, for example.