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Have frequent ulcers on legs. Treated with antibiotics. Test results show superfacial dermis shows fibrin deposition in the vessels. Cure?

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Practicing since : 2006
Answered : 2015 Questions
Dear Sir,
I am 26 yrs old with frequent ulcers on my lower extremity of leg.I had ulcer for 4 times till date on my left leg.

First time (Oct 2008)--- It was small red rash turned into lesion with puss oozing out ( cured using antibiotics)-- no diagnosis made
Second time(Feb 2010)----this time i was treated with antibiotics and trental.( relieved)
Third time( feb 2011)----- a series of antibiotics, swab test ( IV antibiotics given) and skin biopsy done. Dx as erythema nodosum
Skin biopsy result:superfacial dermis shows fibrin deposition in the vessels and perivascular collection of macrophages,lymphocytes,neutrophils.At foci vasculitis changes in the forms of fibrinoid necrosis of vessel wall and presence of neutrophils noted.Deep dermis also show a focu of leucocytoclastic vasculitis

Fourth time( April 2013)-----rashes on leg with one lesion formed.
visited rheumatologist------- wrote skin biopsy again ( doctor thinks it can be PAN like vasculitis,Atrophie blanche,APLA syndrome)----biopsy yet to be done.

Past history:
Epileptic attack at age 14 ( only once and under medication for 8yrs)
Hypertension since 12yrs
operated for the ulcer in ileum at the age of 16 followed by Multiple sclerosis dx( with optic neuritis symptom within a span of 1 month from operation)
Sec attack of Optic neuritis after an yr( 2005)---difference between 2 attacks is 1 yr 8months.

Since then i have no issues till 2008 wherein i had ulcer on my left leg.

Sir my career n job involved long travel and continuous sitting job.Even just 2 days back.. i started developing small red bumps on my leg. I had joint pain with heat developed at joint in leg ankle. it vanished the very next 2 days. The very next day i have little cold liek symptoms with little soar throat.

I feel this ulcers can be due to Chronic venous insufficiency ( 80% of cases of Atrophie blanche is shown off as indication due to CVI , i read this in an article ). But the above old biopsy report says an indication of vasculitis. Is it worth relying on it? or another biopsy can be done involving medium sized artery. ( looking for the inflammation inside the artery)?

Please help me with this Sir.

Posted Sun, 14 Jul 2013 in Medicines and Side Effects
Answered by Dr. Kalpana Pathak 2 hours later
Thanks for writing to us.
Firstly I would like to mention your skin biopsy does not corroborate with erythema nodosum. EN does not ulcerate and histopathologically( skin biopsy) it shows septal panniculitis without vasculitis ie inflammation of fat cells without inflammation of blood vessels. Your biopsy shows inflammation and necrosis of vessels. There could be multiple causes for the same like
Atrophie Blanche
Wegeners granulomatosis
Pyoderma gangrenosum
Autoimmune diseases
Infections, certain medicines etc

Chronic venous insufficiency presents with leg swelling pain discoloration and ulceration.

I would advise that you be under your rheumatologist's guidance. To reach an exact diagnosis a repeat biopsy from the red lesion if any and ulcers is required along with immunoflourescence study and other tests like XXXXXXX etc.

I can just assure that once a proper diagnosis has been made, an appropriate treatment can be instituted to help your lesions heal .

Hope that helped. Should there be any doubt regarding the explanation provided, please write back.
Take care
Above answer was peer-reviewed by
Follow-up: Have frequent ulcers on legs. Treated with antibiotics. Test results show superfacial dermis shows fibrin deposition in the vessels. Cure? 24 minutes later
I have undergone XXXXXXX test n XXXXXXX test too which has come out negative. C reactive protein was positive. The vein doppler came out to be negative.The biopsy result which i have provided was of incisional biopsy of epidermis and dermis.I am really worried if it is going to be PAN....As per my knowledge from internet articles, PAN diagnosis can only be done if the biopsy is of medium sized artery which has not happened in my case. I am planning to go for one more biopsy 2mrw but i am not sure would it give the proper result. As the red bumps are 3 days old and almost turned brown. Please suggest me in this case
Answered by Dr. Kalpana Pathak 25 hours later
thanks for writing back.
C reactive protein is just a marker of acute infection and inflammation and is not diagnostic of any particular skin disease. Normal doppler rules out deep vein thrombosis/ XXXXXXX can be negative in cutaneous PAN(PAN with no systemic complaint).
cutaneous PAN requires a skin biopsy which shows all the blood vessels to be inflammed. no medium artery biopsy is required. PAN can occur in association with bacterial and viral infections like streptococcal infection and hepatitis B etc. so these should be ruled out.
Do not worry just get a biopsy of new lesion done. The differentials to be kept according to me should be
cutaneous PAN
Erythema nodosum
Erythema induratum
atrophie blanche.

All the above mentioned diseases are treatable and can be brought into remission. A proper diagnosis based treatment is required in your case. kindly remain in touch with rheumatologist and dermatologist to treat your concern aptly.
hope that helped. Take care
Above answer was peer-reviewed by
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