A Rapidly Expanding Ulcer—Quiz Case

A 72-year-old woman, who was otherwise healthy, developed a painful ulceration on her right lower extremity after minor trauma. The ulcer started as a small pustule on her right leg and rapidly evolved into a painful ulcer. Initial investigation revealed normal laboratory test results with the exception of an elevated white blood cell count (66.0 × 10³/µL [reference range, 4.5-11.0 × 10³/µL]). Subsequent workup revealed chronic myelomonocytic leukemia, with multiple complex cytogenetic findings, including a 5q– mutation and an absence of the Philadelphia chromosome. Before her hospitalization, the patient underwent surgical debridement, which led to rapid progression of her ulcer and aggravation of her pain.

On physical examination, a 13 × 18-cm ulcerated violaceous lesion with a necrotic center was noted on the patient's right lower extremity (Figure 1). The ulcer had a dusky-red to purple, irregular, undermined border, with a minimal surrounding erythematous halo. The ulcer base was granulating, with a serosanguineous exudate. There were satellite pustules on the surface of the ulcer. There was no regional lymphadenopathy. An incisional biopsy was performed (Figure 2 and Figure 3). The specimen was split and sent for histopathologic and immunofluorescence evaluation, as well as for bacterial, fungal, and atypical mycobacterial culture.

Article