Rheumatoid vasculitis

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Patient is a 74-year-old with an extensive history of juvenile rheumatoid arthritis. Patient went off her treatment for rheumatoid arthritis in 2021. Since then she has developed several chronic ulcers , mainly on her right lower extremity. Patient follow up with a cardiologist and was tested for PAD. The cardiologist diagnosed her with rheumatoid vasculitis. Patient does have an appointment with a rheumatologist February 14. Past treatment of the vascular ulcer consist of topical antibiotic ointment. Iodosorb, and silver, alginate, Current treatment includes Santyl for three more days, silver alginate, and sulfamethoxazole-trimethoprim 800 mg-160 mg oral tablet q.12 hours times 10 days per and culture findings. Any other recommendations until patient can get into the rheumatologist for further treatment of the underlying cause? Of note she does have two smaller wounds on the right lateral aspect of her foot as well.

Jan 11, 2023 by Brenda Baker ,

1 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Brenda

Thanks for sharing this case. Scott Robinson MD, Kye Evans DO FACEP and I talked about it and here are some thoughts:

As part of the checklist to reassess recalcitrant ulcers, it'd be important to review/address comorbidities delaying healing and review potential etiology(ies) of the ulcers. Regarding etiology, it has been described that approximately 10% of patients with rheumatoid arthritis have specific cutaneous features related to their underlying disease. One of these features is leg ulcers, which can be further classified into five distinct clinical types [1]:
(i) pyoderma gangrenosum,
(ii) Felty's syndrome: Felty's syndrome is a rare, potentially serious disorder that is defined by the presence of three conditions: rheumatoid arthritis (RA), an enlarged spleen (splenomegaly) and a decreased white blood cell count (neutropenia), which causes repeated infections [2]
(iii) vasculitic ulcers,
(iv) venous stasis ulcers and
(v) pressure ulcers/injuries

For suspected ulcers due to cutaneous vasculitis, biopsies (H&E and direct immunofluorescence) are important to confirm the diagnosis and identify patients at higher risk of systemic complications. The specimen should be taken at the active edge of the lesion or in the periwound area when new lesions tend to develop.[3]

From the picture, it is not clear whether periwound has signs of cutaneous vasculitis (e.g. a classic cutaneous finding of rheumatoid vasculitis is a medium-vessel inflammatory process associated with ulcerated lesions of the lower extremities). A biopsy would help clarify. Also, it'd be important to rule out "functional venous insufficiency" as a possible cause of the ulcer.[4] Functional venous insufficiency is caused by overloading the veins due to incorrect posture, alterations of the muscle pump or lymphedema. Rheumatoid arthritis could eventually lead to significantly decreased range of motion to the ankle and calf muscle atrophy (alterations of the muscle pump). Cases have been described in which lower extremity ulcers due to functional venous insufficiency in patients with long standing RA eventually healed after compression therapy was initiated (despite lack of the typical edema seen with venous leg ulcers).

Upon reassessment, the plan of care would be adjusted accordingly. For instance, venous insufficiency would require compression therapy. Infection/bioburden should be addressed (it seems like it has been) and inflammatory processes extending beyond the superficial wound base require disease‐specific systemic anti‐inflammatory agents.[1]

For details, please refer to the links below:

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7951223/
[2] https://rarediseases.info.nih.gov/diseases/8234/feltys-syndrome
[3] https://woundreference.com/app/topic?id=cutaneous-vasculitis&find=rheumatoid+vasculitis+ulcer#-diagnosis
[4] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5027257/

Jan 12, 2023

* 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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