58 yr old male with long term open ulcer.

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Pt has had multiple ulcers over 20 years that have closed with minimal wound care. This time the wound has been open for 2 years when he presents to us. ABX and now a wound vac have been employed and we are having great success. We are running a wound hygiene trial which he was randomly placed in which entailed scrubbing of Peri wound and wound bed for 2 minutes each. He was in the hypochlorous acid trial to peri wound and wound bed. We had used this before with no issues on this pt however we had not scrubbed for a set time. The next day the pt had complaint of increased swelling and pain in leg from thigh to foot even though the ulcer is on his shin. We saw him 2 days later in the clinic and it was obvious the wound bed had edema and his lower leg had edema. On this visit we sent him for an ultra sound to rule out DVT, test came back negative so wound vac was reapplied. Pt called the next day saying his leg swelled today from thigh to foot and he had a soft lump in his leg that he could palpate in the thigh to knee. Ideas? Underlying autoimmune? Lymphedema? We have discussed removing epibole edges but with this new issue we need some thoughts.

Mar 2, 2021 by Kim Harris, Nurse Manager Wound Care & HBO

5 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Kim!
Just chatted with Cathy Milne, jotting down here some of our quick questions/thoughts:
- What was the underlying cause of his ulcer? Does the pt have any relevant comorbidities?
- From the close up picture you sent, it seems that the darker area in the wound bed might be deeper than other areas of the wound, is that so?
- Besides edema and pain, are there any other clinical signs/symptoms that might indicate a recent inflammatory/infectious process?
- Is it possible that the cause of the recent edema, pain and soft lump is related to something else? For instance, has the patient had any recent trauma to the leg (e.g. bumped it against an object leading to hematoma?) Or is the pt. on anticoagulants?

Mar 2, 2021

Kim Harris
Nurse Manager Wound Care & HBO

We really don't know the underlying cause, right now we are saying venous but at this point the plan will be to go to OR and get a full thickness biopsy for path. Really no co-morbidities, pt states he has had these off and on for years. The wound is all about 0.3 depth, that day when we took the picture there was edema in the wound bed. There are really no systemic signs of infection and inflammation just happened, he has not had that before. Pt is not on anticoagulants and there has been no trauma to the wound.

Mar 3, 2021

Eugene Worth
MD, M.Ed., FABA, ABPM/UHM

Hi, Kim! Just a couple of thoughts. I first looked at the pictures without reading all of the presentation. My initial thoughts were:
1. Venous Stasis Ulcer
2. Epibole and hypergranulation all over the wound base
3. No evidence of infection
4. Don't have any idea of the mechanism for the swelling ... except inadequate compression.

So, from my perspective, if you go to the OR, debride all of that lovely granulation tissue down to the 'gritty' base. I would also debride the wound edges as well. Clinically, I doubt infection, but a culture from the debrided wound base should help ... On the other hand, VSUs are generally 'dirty' and I usually don't treat unless there is a predominant organism.

Mar 3, 2021

Eugene Worth
MD, M.Ed., FABA, ABPM/UHM

Hi, Kim! Just a couple of thoughts. I first looked at the pictures without reading all of the presentation. My initial thoughts were:
1. Venous Stasis Ulcer
2. Epibole and hypergranulation all over the wound base
3. No evidence of infection
4. Don't have any idea of the mechanism for the swelling ... except inadequate compression.

So, from my perspective, if you go to the OR, debride all of that lovely granulation tissue down to the 'gritty' base. I would also debride the wound edges as well. Clinically, I doubt infection, but a culture from the derided wound base should help ... On the other hand, VSUs are generally 'dirty' and I usually don't treat unless there is a predominant organism.

Mar 3, 2021

Elaine Horibe Song
MD, PhD, MBA

Dr Robinson's arm chair thoughts:
- Could the exacerbation be an acute allergic reaction to the hypochlorous acid that caused some antihistaminic reaction resulting in overwhelming edema and therefore the soft tissue mass of unknown etiology (or more acute fluid than his lymphatics are capable of handling)?
- Otherwise it seems like a large nonhealing VLU
- Agree with biopsy, compression and consider brief course of prednisone

Mar 4, 2021

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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