Clinical Images

Painful Wounds That Won't Heal

Image 1. The largest ulcer was on the right anterior portion of the tibia and measured 8cm x 5cm x 1cm with granulation tissue, central eschar and exposed tendon.

Image 2. Histopathological analysis of the biopsied lesion revealed inflammatory cells, granulation and dystrophic calcinosis

Painful Wounds That Won’t Heal

Authors: Francis Benn M.D., Benjamin Weissman, Ashwad Afzal M.D., Kotresha Neelakantappa M.D.

An 81-year-old man presented for evaluation of lower extremity ulcers of four months duration. The lesions were bilateral, extremely painful and mainly found on the anterior portion of the lower extremities. He had a history of diabetes that was well controlled with diet and end-stage renal disease requiring hemodialysis.  Previous treatment of his ulcers consisted of hyperbaric oxygen therapy, antibiotics and local wound care but without improvement. His home medications included sevelamer 1600 mg three times daily and vitamin D 800 IU daily. He denied smoking in the past and drank alcohol on occasion.

On examination, he was in mild degree of discomfort, afebrile and normotensive. He had bilateral superficial lower extremity ulcers that were extremely tender. The largest ulcer was on the right anterior portion of the tibia and measured 8cm x 5cm x 1cm with granulation tissue, central eschar and exposed tendon (See Image 1).  Laboratory investigations revealed a serum calcium of 8.3 mg/dl and a phosphate level of 5.5 mg/dl. Histopathological analysis of the biopsied lesion revealed inflammatory cells, granulation and dystrophic calcinosis (See Image 2).

What is the likely cause of the lesions?

A. Venous stasis ulcer

B. Cellulitis

C. Necrotizing fasciitis

D. Calciphylaxis cutis

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