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Table of Contents   
CASE REPORT  
Year : 2017  |  Volume : 10  |  Issue : 6  |  Page : 1820-1823
Atherosclerosis-induced leg ulcers in a young female unassociated with risk factors: A rare presentation of a systemic disease


Department of Dermatology, SVS Medical College, Mahbubnagar, Telangana, India

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Date of Web Publication11-Jan-2018
 

   Abstract 


The occurrence of arterial leg ulcers due to atherosclerosis is common among old individuals. However, the development of leg ulcers due to atherosclerosis in a young female unassociated with risk factors like hyperlipidemia is rare. Herein, we present a case of leg ulcers consequent to atherosclerosis in a young female having normal lipid profile and unassociated with other risk factors. Characteristic morphology and site of the ulcers along with supportive investigations such as color Doppler study and histopathology of ulcer corroborated in establishing the diagnosis.

Keywords: Ankle-brachial index, atherosclerosis, color Doppler, punched out ulcer

How to cite this article:
Rao AG, Reddy UD, Karanam A, Kolli A, Javadevapuram K, Hakkani R, Farheen SS. Atherosclerosis-induced leg ulcers in a young female unassociated with risk factors: A rare presentation of a systemic disease. Ann Trop Med Public Health 2017;10:1820-3

How to cite this URL:
Rao AG, Reddy UD, Karanam A, Kolli A, Javadevapuram K, Hakkani R, Farheen SS. Atherosclerosis-induced leg ulcers in a young female unassociated with risk factors: A rare presentation of a systemic disease. Ann Trop Med Public Health [serial online] 2017 [cited 2018 May 22];10:1820-3. Available from: http://www.atmph.org/text.asp?2017/10/6/1820/222639



   Introduction Top


Atherosclerotic vascular disease is a diffuse progressive condition symbolized by accumulation of lipids, inflammatory cells, and fibrous components in the large arteries.[1] It is the leading cause of death in western countries since many decades.[2] It usually affects multiple arteries and the clinical manifestations include coronary heart disease, cerebrovascular disease, and peripheral artery disease.


   Case Report Top


A 34-year-old homemaker presented with multiple painful ulcers over both legs of 2-month duration. She was asymptomatic 2 months ago then she developed painful swelling on the lateral aspect of the right ankle, which subsequently ulcerated resulting in large ulcer. History of development of similar ulcers on both legs in identical fashion. She used to experience pain in the calves while walking a distance longer than her usual walking distance. Raynaud's phenomena were absent. No history of smoking or tobacco abuse. Not associated with joint pains, fever, photosensitivity, or loss of weight. No history of palpitation, breathlessness, or syncope. She has been on medication for hypothyroidism for the past 8years. No history of hyperlipidemia in the family. She is not a known diabetic or hypertensive. Vital data; Blood Pressure(BP):130/90 mmHg, heart sounds were normal. On examination, there were two ulcers one large ulcer on the right ankle and a small one on the left ankle. The large ulcer on the lateral aspect of right ankle was circular, about 2.5 cm in diameter, well-defined, tender, dry covered with yellow crusts[Figure1]. The small ulcer was located on the anteromedial aspect of left ankle measuring 1 cm in diameter, punched out, edematous pigmented border, and covered with yellow crusts[Figure2]. Asmall atrophic plaque with surrounding pigmentation was also noted on the medial aspect left lower leg. The skin on both feet was shiny with sparse hair. Dorsalis pedis arterial pulsations on both sides were absent and other peripheral pulses were felt and normal. There was no evidence of varicose veins. No nerve thickening and no motor or sensory deficit. Inguinal lymph nodes on both sides were found enlarged, tender, and not matted. With these clinical features she was diagnosed as arterial ulcer; however, Martorell's ulcer, venous ulcer, and vasculitis were considered in the differential diagnosis.
Figure1: Large circular ulcer on the lateral aspect of right ankle, well-defined, dry, covered with yellow crusts. Edema foot and pigmentation is seen

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Figure2: Ulcer on the anteromedial aspect of the left ankle, punched out, edematous pigmented border, covered with yellow crusts. Multiple healed atrophic scars near lower border of ulcer can be seen

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Routine blood investigations including blood sugar, liver function test, renal function test, and serum total cholesterol: 190mg/dl, high-density lipoprotein: 65mg/dl, low-density lipoprotein(LDL) cholesterol: 112mg/dl, Very LDL 25mg/dl, triglycerides: 132mg/dl. Serum calcium and serum uric acid were normal and sickling test was negative. Coagulase-negative staphylococci were grown on culture from pus. Antinuclear antibody test, rheumatoid factor, human immune deficiency virus, VDRL test, hepatitis C antibodies, antiphospholipid antibody test, cryoglobulins were negative. Fibrinogen 250 mg/dL(normal 200–400mg/dL). Smear from ulcer for Mycobacterium tuberculosis, fungus and Leishmania was negative. Mantoux test was negative. Chest skiagram, ultrasonography of abdomen, X-ray lumbosacral spine, and both lower limbs were normal. Ankle-brachial index was 0.7. Transcutaneous oxygen pressure(TcPo2) measurement could not be determined due to nonavailability. Electrocardiogram and two-dimensional Echo was normal. Color Doppler study of arterial and venous system revealed diffuse atherosclerotic changes in femoral, popliteal, anterior and posterior tibial arteries with competent venous system[Figure3] Histopathological examination of biopsy taken from margin of ulcer showed thick walled arterioles in edematous background along with few inflammatory cells in the dermis consistent with the diagnosis of atherosclerosis[Figure4]. She was referred to vascular surgeon for further management.
Figure3: Color Doppler study showing diffuse atherosclerotic changes in femoral, popliteal, anterior and posterior tibial arteries with competent venous system

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Figure4: Histopathological examination of ulcer showing thick-walled arterioles in edematous background along with few inflammatory cells in the dermis(HandE, ×40)

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   Discussion Top


Chronic ulceration of the legs is a relatively common condition among adults, about 10% of the population develop chronic ulcer with a wound-related mortality rate of 2.5%.[3],[4] It has been reported that 70% of leg ulcers are venous, 10% arterial, and 15% are of mixed etiology.[5] Ulceration of legs due to atherosclerosis is common among geriatric population, compounded by the risk factors such as diabetes mellitus, obesity, elevated LDL, hypertension, elevated fibrinogen and smoking. The reported incidence of leg ulcers due to atherosclerosis ranged between 10% and 16.3%.[6],[7],[8]

Leg ulcers in the index case could be due to atherosclerosis as the patient is a young female presented with painful, tender, punched out ulcers, substantiated by color Doppler study which showed diffuse atherosclerosis of lower limb arteries and thickening of arterioles on histopathology. However, it is enigmatic that the young female with normal lipid profile and unassociated with risk factors developed such extensive atherosclerosis of lower limb arteries leading to leg ulcers. The presence of pain and absence of varicose veins and dorsalis pedis pulsations in the index case disapprove the diagnosis of venous ulcer. Martorell's ulcer was ruled out as the female is not hypertensive and there is lack of characteristic morphology and site of ulcers. Punched out ulcers and absence of histopathological features of vasculitis in the index case undermine the diagnosis of vasculitis. Monckeberg's arteriosclerosis(MA) could not be contemplated in the index case as she is a young female whereas MA is age-related degenerative process and radiography also did not display calcification of arteries [9][Table1].
Table 1: Differential diagnoses of chronic leg ulcers

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Atherosclerotic obstruction usually occurs in the iliac, femoropopliteal, peroneal and tibial arteries which subsequently, leads to reduced arterial blood flow causing decreased tissue perfusion ultimately resulting in ulcer formation.[10] Moreover, peripheral vascular disease due to diabetes with microvascular or macrovascular disease could also lead to ischemia resulting in ulceration.[11] The resulting ulcer development is rapid with deep destruction of tissue. The development of arterial ulcers in the index case not being diabetic is notable. In addition, these patients also have profound endothelial and platelet activation secondary to a proinflammatory/prothrombotic state, among other complex processes. Furthermore, thrombotic events due to emboli from the heart, aneurysms, plaques, and hypercoagulable states may also be responsible for developing ischemic ulcers. However, there is no clinical or imageological evidence of thrombus in the heart or aneurysm in the index case. There is substantial overlap and precise pathogenesis cannot always be determined. Arterial ulceration characteristically occurs over the toes, heels, shin, and bony prominences of the foot. The ulcer appears “punched out” with well-demarcated margins and pale, nongranulating necrotic base.[10] The morphology and the site of leg ulcers in the index case is in concert with typical arterial ulcer. Usually, these patients present with distal pain and intermittent claudication and they complain of pain on elevation of feet, especially at night, and reduction of pain on dependency. However, patients may not experience pain until 70% of the artery is occluded.[5] In agreement with this, our case also did not experience pain despite atherosclerosis of lower limb arteries as evidenced by color Doppler study. Patients with peripheral arterial insufficiency are 3–6times more likely to have a coronary heart disease(CAD) or cerebrovascular disease(CVD)[12] However, there is no association with CAD or CVD in the index case. Characteristic morphology and site of ulcer and investigations(ankle-brachial index [13] and TcPo2 measurement, color Doppler studies, magnetic resonance imaging angiography) assist in establishing the diagnosis of arterial insufficiency. The management of atherosclerotic ulcers includes revascularization, lipid-lowering agents, cessation of smoking, control of BP, control of blood glucose and antiplatelet agents(aspirin, ticlopidine, and clopidogrel) and pentoxifylline.


   Conclusion Top


The presentation of leg ulcer as a manifestation of systemic disease such as atherosclerosis could be an iceberg of the underlying severe life-threatening condition such as coronary heart disease and cerebrovascular disease. Hence, extensive workup is imperative in such a presentation to unravel underlying systemic disease.

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Conflicts of interest

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   References Top

1.
FaxonDP, CreagerMA, Smith SC Jr., PasternakRC, OlinJW, BettmannMA, etal. Atherosclerotic Vascular Disease Conference: Executive summary: Atherosclerotic Vascular Disease Conference proceeding for healthcare professionals from a special writing group of the American Heart Association. Circulation 2004;109:2595-604.  Back to cited text no. 1
    
2.
MakaryusA. Cardiovascular imaging for the assessment of atherosclerotic disease: Implications for cardiac risk stratifications. Curr Cardiovasc Risk Rep 2008;3:107-12.  Back to cited text no. 2
    
3.
MoffattCJ, FranksPJ, DohertyDC, SmithdaleR, MartinR. Sociodemographic factors in chronic leg ulceration. Br J Dermatol 2006;155:307-12.  Back to cited text no. 3
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4.
ChatterjeeSS. Venous ulcers of the lower limb: Where do we stand? Indian J Plast Surg 2012;45:266-74.  Back to cited text no. 4
[PUBMED]    
5.
CaseyG. Causes and management of leg and foot ulcers. Nurs Stand 2004;18:57-8, 60, 62.  Back to cited text no. 5
[PUBMED]    
6.
O'BrienJF, GracePA, PerryIJ, BurkePE. Prevalence and aetiology of leg ulcers in Ireland. Ir J Med Sci 2000;169:110-2.  Back to cited text no. 6
    
7.
Körber A, KlodeJ, Al-BennaS, WaxC, SchadendorfD, SteinstraesserL, etal. Etiology of chronic leg ulcers in 31,619patients in Germany analyzed by an expert survey. JDtsch Dermatol Ges 2011;9:116-21.  Back to cited text no. 7
    
8.
CaseyG. Causes and management of leg and foot ulcers. Nurs Stand 2004;18:57-8, 60, 62 passim.  Back to cited text no. 8
[PUBMED]    
9.
Monckeberg JG. About the pure media calcification of extremity species and their behavior to arteriosclerosis. Virchows Archivbfur Pathological Anatomic and Physiology for Clinical Medicine. Vol 171. Berlin; 1903. p. 141-67.  Back to cited text no. 9
    
10.
MoffattC. Leg ulcers. In: MurrayS, editor. Vascular Disease. London UK: Whurr Publishers; 2001. p.200-37.  Back to cited text no. 10
    
11.
GornikHL, BeckmanJA. Cardiology patient page. Peripheral arterial disease. Circulation 2005;111:e169-72.  Back to cited text no. 11
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12.
JohanssonK, BehreCJ, Bergström G, SchmidtC. Ankle-brachial index should be measured in both the posterior and the anterior tibial arteries in studies of peripheral arterial disease. Angiology 2010;61:780-3.  Back to cited text no. 12
    
13.
Aboyans V, Criqui MH, Abraham P, Allison MA, Creager MA, Diehm C, et al. Measurement and interpretation of the ankle-branchial index. A scientific statement from the American Heart Association. Circulation 2012;126:2890-909.  Back to cited text no. 13
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Correspondence Address:
Angoori Gnaneshwar Rao
F12, B8, HIG-II APHB, Baghlingampally, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ATMPH.ATMPH_195_17

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