I will be interested to hear my other colleagues thoughts on this. I agree that this is an atypical presenting wound in a very complex patient. I’m wondering if the patient’s IVC pumps are a large contributing factor to this as most of the damage appears to be posterior. The length of the wounded area and the distal tibial necrosis(? tendon..unable to discern with the picture) I have to think that there may be an element of pressure also as there is more damage on the posterior aspects. It would be nice to know what kind of medications this patient is currently on and what medications he may have received over the last month that could have contributed to the etiology of this wound. Clearly his platelets are low, which also contribute to the discoloration...

Wow!! This is a complicated patient. I'd say that all the diagnoses you have stated are pretty good. Calciphylaxis is a stretch ... but, minor quibble.

I'm suggesting a measured and targeted approach to a difficult and unknown wound. Bob Kirsner, in a paper probably 8 years ago, took a series of 350 wound biopsies, 104 of them were 'atypical.' He studied biopsy results from the 104 ... 24 were neoplasm, 14 were pyoderma, and 16 were vasculitis. So, a pathology diagnosis in over half of the 'atypical' wounds.

Tang JC, Vivas A, Rey A, Kirsner RS, Romanelli P. Atypical Ulcers: Wound biopsy results from a University wound pathology service. Ostomy Wound Management 2012;58(6):20-29.

A paper by Wirthlin (vascular surgeon) and colleagues looked at making diagnosis of wound types and severity by photograph alone. Bottom line is that wounds were over-classified and over-treated. So, I'll pass on doing that except to say that the wound looks 'wet' and would probably cover most open areas with an absorptive foam. If the leg could stand it ... also consider mild concentric compression (double layer of Tubigrips).

The measured approach to this wounding is to get multiple biopsies. I would use an excisional (elliptical) biopsy that starts in 'normal' tissue and extends into the wound base itself. Punch biopsies might give you a diagnosis but our dermatopathologist really wanted to get specimens that had 'normal' to abnormal progression at the edge of the wound. So, I would probably send at least two specimens to derm-path. I would take a third ellipse and send it to microbiology in saline (rather than fixative) asking for C&S as well as fungal cultures. The specimen gives you much more likelihood for a microbiological diagnosis rather than swab cultures.

With that said, please report back with more details.

Definitely need biopsy to see what it is, is the patient on coumadin. Coumadin necrosis or maybe pyoderma would be my guess.

Hi team, thank you for your thoughts! Our colleague appreciates your responses and agrees with your insightful suggestions. Colleague will encourage bx and report back after the surgical debridement.
Some more info: regarding meds, patient is taking several - colleague shared a list (attached) but can't tell which ones the patient was taking at home and which ones were initiated post admission. Coumadin is not on the list. The patient was ambulatory prior to this episode.
Thank you, will post more as soon as I hear more about it!

Hi team, thank you for your thoughts! Our colleague appreciates your responses and agrees with your insightful suggestions. Colleague will encourage bx and report back after the surgical debridement.
Some more info: regarding meds, patient is taking several - colleague shared a list (attached) but can't tell which ones the patient was taking at home and which ones were initiated post admission. Coumadin is not on the list. The patient was ambulatory prior to this episode.
Thank you, will post more as soon as I hear more about it!