Lesions on bilateral legs

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: August 18, 2014

CHIEF COMPLAINT: Lesions on bilateral legs

CLINICAL HISTORY: The patient reports lesions on bilateral legs with significant swelling and malodor. The patient denies pain or pruritus at this time. The patient presented to the emergency department in atrial fibrillation with a rapid ventricular response.

PHYSICAL EXAM:
On physical exam, bilateral legs revealed extensive non- pitting edema with overlying hyperkeratotic, verrucous plaques.

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. The lesions were malodorous.

LABORATORY TESTS:

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 an ejection fraction of 20%, moderate-severe pulmonary hypertension, and no evidence of DVT. Laboratory findings indicated the patient was also in renal failure.

DERMATOHISTOPATHOLOGY:

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 fibroplasia, and sparse chronic inflammation.