42 - Case Study II Flashcards
Chief complaint
- 38 year old female
- Painful bump on front of lower left leg
- No history of trauma
- Rapid development over a 24 hour period
- No prior episodes
- No treatment
- Generalized fatigue and “achy ankles” for 2 weeks
Medical history
- Penicillin allergy (rash, no anaphylaxis, avoided since then)
- Procardia for hypertension
- Protonix for heartburn and gastric reflux during “times of stress”
- Periods of diarrhea over the past 3 years
Social history
- Elementary school teacher
- Non-smoker
- Has children
Surgical history
Appendectomy 5 years ago
- Colonoscopy
Family
Unremarkable
ROS
- Denies thyroid, heart disease, emphysema, cancer, asthma, diabetes, stroke
- Does have cardiopulmonary and hypertension
- Gastric reflux and heartburn, diarrhea
- Bilateral ankle discomfort, occasional back pain
- No bleeding tendencies
- No previous skin ulceration,cancer or irritation
Physical exam
- Pleasant and well-oriented
- Temp 100.2, others normal
- Foot pulses +2/4 bilaterally, mild swelling around ankles
- Neurologic sensation in tact, 5+ muscle strength
- Discomfort of ankle range of motion
Describe the bump
Blister, 2-3 cm in diameter
- Bulla is typically 3 or more cm
- Vesicle is usually less than cm
- In between that is a blister
- They are all fluid filled
- Will breakdown and form an ulcer
- Always important to determine if a lesion was first a blister or just started as an ulcer
Her blister
- Raised fluid filled lesion on anterior aspect of left lower leg
- Warm to touch and very tender
- Lesion and surrounding tissue is tense
- Slight erythema and warmth noted around ankles
- The warmth was slight, no coolness below warmth indicating there is good circulation
Diagnostic tests
- I and D (irrigation and debridement)
- CBC with diff
- C-reactive protein, sed rate (inflammation)
- Biopsy
- Fluid sample
- X-ray to see foreign body and of ankles
- Rheumatoid factors
Ankle x rays
- Soft tissue swelling with joint distension
- No bone pathology
- Joint line looked like there was diffusion and distenstion of the bones themselves
CBC
- RBC 4.2
- Hct 36
- Hemoglobin 11
A little low, maybe a little anemia going on (not that uncommon in inflammatory bowel disease - IBS, Crohn’s)
Sed rate
45
High, ulcerative collitis is acting up (likely)
Aspiration and culture of lesion
Yellow brown fluid
- Negative gram stain
Biopsy
- Extensive neutrophilic infiltration
- Hemorrhage and necrosis of the overlying epidermis
- Vasculitic appearing
Didn’t debride it because I didn’t know what it was - waited for the results (24 hours)
Other tests
- HLAB27 and Rh factor for reumatoid arthritis
- No MRI yet
Clinical questions
Are there lower extremity derm pathologies associated with inflammatory bowel disease?
What is the pathophysiology of these derm conditions?
Are there bone and joint pathologies associated with inflammatory bowel disease?
What is the pathophysiology of these bone or joint conditions?
Lower extremity derm conditions associated with IBD
- Nodules (like little rubber balls in the cutaneous tissue)
- Surrounded by erythemaous border
- Called erythema nodosum
Erythema nodosum
- Hypersensitivity reaction
- Red, tender, painful pretibial nodules
- Appear in crops
- Systemic symptoms
- More often a sign of other diseases (streptococcal infection, sarcoidosis, TB, sulfa antibiotics, oral contraceptives, IBD… )
- Treatment?
Our patient probably does NOT have erythema nodosum because this does not look like our patient
What other derm condition on the lower extremity is associated with IBD?
Pyoderma gangrenosum
- Starts out as a blister
- Breaks down into an ulcer
- Papulovesicle/pustule
- Rapid necrosis
- Necrotizing vasculitis
- Erythematous halo with rolled borders
- painful, will heal with atrophic scar
- Also related to RA, myeloproliferative diseases, hepatitis drug reactions
- 50% unknown cause
How many patients with inflammatory bowel diseases will have a derm condition?
10-15% of inflammatory bowel disease will have one of these derm condition
Slide text: 5-10% of IBD cases have dermatological manifestations
“Actually more common than that, probably more like 15%)
What is the pathophysiology of derm conditions associated with IBD?
- Vasculitic***** appearing process
- Inflammatory necrosis of blood vessel walls
Abnormal immunologic response*****
- Immune complex deposition
- Inflammatory infiltrate (neutrophilic) ***
- Fibrinoid necrosis of vessels
- Tissue infarction
- Ulceration
REMEMBER: vasculitic and an immunologic response with neutrophils ***
Bone and joint patholgoies associated with IBD
Enteropathic arthritis
- AKA reactive arthritis
There are two areas that tend to be involved:
- Ankylosing spondilitis (back pain)
- Peripheral pain (periphery)
Describe peripheral arthritis
Peripheral arthritis
- Classified as seronegative spondyloarthropathy
- 10-20% associated with IBD
- May be the first clinical sign of IBD
- Knees, ankles and feet most commonly involved
- Lack erosive changes
- Synovial fluid analysis (class II)
- HLA-B27 (present in joint fluid)
Pathophysiology of bone and joint conditions associated with IBD
FINISH THIS **
- Unknown
- Antibodies to enteric
?????
Diagnosis and management plan
Primer on the rheumatic disease
Describe the required reading for this lecture
Pyoderma gangrenosum mimicking diabetic foot infections: a case report
There will be a test question on this ***
Don’t do an MRI, CT, bone scan too quickly (second level diagnostic tests when looking at skin lesions)
How these things are managed are very different (diabetic infection and pyoderma gangrenosum)
Describe treatment of this patient
- Treat the underlying disorder (ulcerative collitis)
- Do not prescribe NSAIDs
- Put her on prednisone for the leg, but this is also the treatment for ulcerative collitis
- As the wound broke down, good wound management helped her
- Family medicine kept her on prednisone after the leg needed it to continue treating ulcerative colitis
