NEJM 「Case Records」
March 8, 2007さんへのお返事です。 > A 59-year-old woman was admitted to the hospital because of a nonhealing ulcer on the right heel and painful ulcers on the right thigh and hip. > > The patient had been morbidly obese since early childhood; she had had type 2 diabetes mellitus and hypertension for 30 years and chronic renal insufficiency for 6. Painless ulcers had developed on the plantar surfaces of both heels 6 years earlier; those on the left side had healed with wound care and decreased weight bearing, but those on the right recurred when she resumed weight bearing. Four years before admission, she became unable to walk because of the ulcers, and moved to a long-term care facility. The chronic renal insufficiency progressed, and hemodialysis was begun 8 months before admission. > > Three months before admission, a large area of purple discoloration and tenderness appeared along the back of her right lower thigh. This area subsequently ulcerated. Two months before admission, an ulcer developed over the greater trochanter of the right hip. Computed tomographic (CT) scanning of the thigh performed 3 months before admission was interpreted as showing cellulitis. Ultrasound imaging of the right leg was negative for deep venous thrombosis. > > At approximately the same time, an ulcer on the right heel that had been present for about 2 years enlarged despite local care and attempts at primary closure. Approximately 2 months before admission, cultures of this ulcer yielded growth of Pseudomonas aeruginosa that was susceptible to ciprofloxacin and gentamicin, and intravenous therapy with these agents was started. Approximately 1 month before admission, a limited bone scan suggested the presence of osteomyelitis of the right calcaneus. Noninvasive vascular studies revealed an anklebrachial index of 0.83 on the right and 0.90 on the left (normal, >0.96). Right calcaneal resection and placement of a vacuum-assisted closure dressing were performed 3 weeks before admission. Cultures of the resected bone grew the same species of P. aeruginosa, as well as Escherichia coli. Ciprofloxacin and gentamicin were continued. > > On follow-up examinations, the heel ulcer did not improve; it became painful, with a purulent discharge, and an area of redness and swelling developed around it. The ulcers on the right hip and thigh increased in size. She was referred to the vascular-surgery clinic of this hospital 10 days before admission. At that time, there was an ulcer, 3 cm deep, on the right hip; a black, necrotic area, 15 cm by 15 cm, on the right posterior thigh; and a decubitus ulcer, 5 cm by 5 cm, on the right heel with exposed bone. None of the ulcers were purulent. Noninvasive vascular study of both legs was recommended. During the next 10 days, her physicians became increasingly concerned about sepsis from the foot ulcer, and she was sent to the emergency department of this hospital. > > On examination, her vital signs were normal and the right lower leg was painful on any movement; the ulcers were unchanged. Examination by vascular ultrasound imaging was limited because of pain but revealed right distal popliteal-artery and tibial-artery disease with poor perfusion of the right foot. She was admitted to the hospital for a below-the-knee amputation of the right leg. > > She did not have fever, chills, or sweats. She had diabetic retinopathy, neuropathy, and carotid and coronary atherosclerosis; carotid endarterectomy had been performed in the past because of transient ischemic attacks. She had had episodes of congestive heart failure with pulmonary edema but had no history of venous or arterial thromboses. She had no known allergies. She was unmarried, had a 16-year-old daughter, and had worked as a teacher until becoming disabled because of the ulcers. She had a 5-pack-year history of cigarette smoking, but had stopped smoking 5 years before admission. She did not drink alcohol or use illicit drugs. Her medications, in addition to the antibiotics, included simvastatin, furosemide, lisinopril, metoprolol, insulin, calcium carbonate, sevelamer, famotidine, gabapentin, narcotics for the pain from her ulcers, and laxatives. > > On examination, the patient was an obese woman who was lethargic but arousable and oriented. She was in moderate discomfort from pain in her right leg. The axillary temperature was 37.4, the blood pressure 137/58 mm Hg, and the pulse regular at 72 beats per minute. Auscultation of the lungs and heart were normal; the abdomen was obese, with no tenderness or organomegaly. The carotid and radial pulses were normal. The left dorsalis pedis pulse was diminished, and the right was not palpable. An ulcer, 5 cm by 5 cm, overlying the trochanter of the right hip exposed the subcutaneous tissue without purulence or erythema. On the right posteromedial thigh, an exquisitely tender and violaceous indurated area, 15 cm by 15 cm, with black, dry ulcerations and surrounding tender erythema, extended from the popliteal fossa two thirds of the way up the thigh. An ulcer, 5 cm by 5 cm, on the right heel had cyanotic margins and a foul-smelling purulent base that exposed bone. An area of erythema that was tender to palpation spread from the heel about two thirds of the way up the lower leg. Laboratory test results are shown in Table 1. > > During the evening, a repeated examination disclosed that the area of erythema on the lower leg now extended to the knee. The patient continued to have severe pain of the calf and posterior aspect of the thigh. A procedure was performed early the next morning. > > ---------- > > Table 1. Results of Laboratory Tests on Admission.
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