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16 December 2010

Large leg ulcers due to autoimmune diseases

Alexander P. RozinABCDEF, Dana EgoziABCDEF, Yehuda RamonABCDEF, Kohava ToledanoAB, Yolanda Braun-MoscoviciAB, Doron MarkovitsAB, Daniel SchapiraAB, Reuven BergmanAB, Yehuda MelamedABDE, Yehuda UllmanABDE, Alexandra Balbir-GurmanABDE

DOI: 10.12659/MSM.881308

Med Sci Monit 2011; 17(1): CS1-7

Abstract

Background: Large leg ulcers (LLU) may complicate autoimmune diseases. They pose a therapeutic challenge and are often resistant to treatment. To report three cases of autoimmune diseases complicated with LLU.
Case Report: Case 1. A 55-year old woman presented with long-standing painful LLU due to mixed connective tissue disease (MCTD). Biopsy from the ulcer edge showed small vessel vasculitis. IV methylprednisolone (MethP) 1 G/day, prednisolone (PR) 1mg/kg, monthly IV cyclophosphamide (CYC), cyclosporine (CyA) 100mg/day, IVIG 125G, ciprofloxacin+IV Iloprost+enoxaparin+aspirin (AAVAA), hyperbaric oxygen therapy (HO), maggot debridement and autologous skin transplantation were performed and the LLU healed. Case 2. A 45-year old women with MCTD developed multiple LLU’s with non-specific inflammation by biopsy. MethP, PR, hydroxychloroquine (HCQ), azathioprine (AZA), CYC, IVIG, AAVAA failed. Treatment for underlying the LLU tibial osteomyelitis and addition of CyA was followed by the LLU healing. Case 3. A 20-year-old man with history of polyarteritis nodosa (PAN) developed painful LLU’s due to small vessel vasculitis (biopsy). MethP, PR 1 mg/kg, CYC, CyA 100 mg/d, AAVAA failed. MRSA sepsis and relapse of systemic PAN developed. IV vancomycin, followed by ciprofloxacin, monthly IVIG (150 g/for 5 days) and infliximab (5 mg/kg) were instituted and the LLU’s healed.
Conclusions: LLU are extremely resistant to therapy. Combined use of multiple medications and services are needed for healing of LLU due to autoimmune diseases.

Keywords: Methylprednisolone - therapeutic use, Leg Ulcer - therapy, Larva, Hyperbaric Oxygenation - methods, Hydroxychloroquine - therapeutic use, Cyclosporine - therapeutic use, Cyclophosphamide - therapeutic use, Ciprofloxacin - therapeutic use, Azathioprine - therapeutic use, Autoimmune Diseases - pathology, Antibodies, Monoclonal - therapeutic use, Prednisolone - therapeutic use, Skin Transplantation - methods, Vancomycin - therapeutic use, Vasculitis - complications, young adult

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