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A 51-year-old man is admitted to the hospital with painful ulcers on both lower extremities, severe anemia, and a 45-kg (100-lb) weight loss over the past year. Pain from the ulcers prevents him from walking. The ulcers developed about 5 years earlier, as a result of his wearing high boots for work; they began as small sores and grew over time.
HISTORY
The patient had varicose vein stripping surgery in his right leg in 1997. He denies alcohol and tobacco use but does report a 30-year history of crack cocaine use; he currently uses cocaine about once a week. He denies melena, hematemesis, hemoptysis, and hematuria. His last primary care visit was 3 years earlier.
PHYSICAL EXAMINATION
This cachectic man appears older than his stated age and is in mild discomfort. Vital signs are normal except for tachycardia (heart rate, 115 beats per minute). His height is 1.93 m (6 ft 5 in), and his weight is 64 kg (142 lb); his body mass index is 16.8. Head, ears, eyes, nose, and throat are normal. He has extremely poor dentition, with few remaining teeth. His neck is supple, without bruits or lymphadenopathy. Chest is clear, and heart rhythm is regular, without murmurs. His abdomen is soft, without masses. Results of a fecal occult blood test are negative.
A 17.5 x 26-cm ulcer is visible over the distal tibia of the right leg. In the left leg, a 16 x 27-cm ulcer is seen over the medial aspect of the distal tibia. Both ulcers are above the malleoli. The ulcers are foul smelling, with a filmy exudate. There is minimal peripheral edema and no evidence of cellulitis. Dry gangrene is evident in the second toe of the right foot. Femoral artery and dorsalis pedis pulses are 2+ bilaterally.
LABORATORY AND IMAGING RESULTS
An initial complete blood cell count reveals a hemoglobin level of 6.6 g/dL, hematocrit of 21.3 mL/dL, and a mean corpuscular volume of 67 fL. The metabolic panel shows a total protein level of 5.6 g/dL, an albumin level of 2.4 g/dL, and a prealbumin level of 10 mg/dL. Total cholesterol level is 90 mg/dL. Hemoglobin A1c is 6.1%.
An MRI scan of both lower extremities shows no osteomyelitis. A venous duplex scan shows no venous thrombosis or venous valvular incompetency above the knee bilaterally; circulation below the knee cannot be evaluated because of pain. Results of a purified protein derivative tuberculin skin test; tests for HIV infection and hepatitis A, B, and C; measurement of lactate dehydrogenase levels; and testing for antinuclear antibodies and rheumatoid factor are all negative. Blood cultures grow no organisms. Wound cultures grow Proteus vulgaris that is resistant to ampicillin and cefazolin, Proteus mirabilis that is pansensitive, and Staphylococcus aureus that is resistant to ampicillin. The patient refuses colonoscopy and esophagogastroduodenoscopy.
What is the most likely cause of this patient’s ulcers?
A. Arterial insufficiency.
B. Venous insufficiency.
C. Uncontrolled diabetes.
D. Malignancy
(answer on next page)
