Presenter: Jeffrey Collins, BS, Michelle Duff, DO, Jason Barr, DO, Richard L. Averitte Jr., MD, Christine C. Lin, MD
Dermatology Program: Affiliated Dermatology
Program Director: Jason Barr, DO
Submitted on: Aug 18, 2014
CHIEF COMPLAINT: Lesions on bilateral legs.
Signs and symptoms: The patient reports significant swelling and malodor. The patient denies pain or pruritus at this time.
Other information: The patient presented to the emergency department in atrial fibrillation with rapid ventricular response.
On physical exam, bilateral legs revealed extensive non- pitting edema with overlying hyperkeratotic, verrucous plaques (Figure 1).
Lateral aspects of the calves bilaterally revealed ulceration. The largest ulceration measured 7 cm. Bilateral thighs revealed several scattered papillomatous cobblestone like papules and plaques (Figure 2). The lesions were malodorous.
Cultures of the lesions revealed heavy growth of gram negative bacilli and few gram positive cocci in pairs, chains and clusters. Blood cultures were negative. Echocardiogram revealed ejection fraction of 20%, moderate-severe pulmonary hypertension, and no evidence of DVT. Laboratory findings indicated the patient was also in renal failure.
A punch biopsy was taken from the advancing edge of the verrucous plaque from the right lower leg which revealed mild acanthosis with diffuse dermal fibroplasia , vascularity and chronic inflammation. A shave biopsy was taken from the cobblestone lesion on the upper thigh which revealed mild papillary epidermal hyperplasia with dermal edema, delicate fibroplasias and sparse chronic inflammation.
1. Venous Stasis Dermatitis
3. pretibial Myxedema