Aug 092013

There have been many such cases I’ve encountered over my years that were either undiagnosed for too long, or misdiagnosed. This case just happens to be the worst to stick out in my mind.

A 62-year-old male without diabetes and otherwise healthy who initially presented to his primary care provider (PCP) several years ago for the first bout of infected lower leg skin along with swelling.

He was appropriately prescribed antibiotics, but the improvement was short-lived, and over a relatively short span of time, this cycle continued, and each episode caused more skin damage, to the point where the skin in the lower legs near his ankles began breaking down forming painful ulcerations in the skin, some getting infected secondarily and several hospitalizations for more powerful IV antibiotics. The severity of this problem led to his referral to a wound care center (WCC). The WCC ruled out arterial disease of the legs as reason for his problem, and like a WCC does, employed tissue debridement, whirlpool therapy, and other newer tissue products to help heal his ulcers. The problem remained: every time the WCC healed the wound, since no definitive reason was discovered, it wasn’t long before the skin ulcerations and related pain/suffering recurred.

Dr. Bell: “This patient wandered in to my office at the suggestion of his friend several frustrating years in to this ordeal. The patient had no visible varicose veins, but had the chronic skin irritation of both lower legs and an active ulceration very suggestive of occult venous disease. The first thing I inquired from the patient and confirmed in available medical notes, was no lower extremity venous ultrasound had ever been performed. That was the key first thing I performed on this patient, and not surprisingly, showed bilateral saphenous vein disease, and the anatomy by sonogram confirmed it was easily amenable to laser. Just a short time later, I closed the offending diseased saphenous veins with laser, and as you might imagine, the chronically irritated skin in the lower legs improved significantly, and the skin ulcer and associated pain resolved in just over a week. Further, since the vein problem was eradicated, he has maintained much healthier skin and has had NO further skin ulcer breakdown problems.

“This is not just my experience with this one patient, but similarly numerous patients.  And this information is readily relayed in published vein medical papers, and similar stories are relayed by my vein colleagues.”

Moral of this story: For unknown reasons, WCCs do not routinely employ venous ultrasound of the lower extremities as a screen for every patient enrolled. VSA is extremely happy for this patient that his legs are much healthier now. The only regret is that he didn’t cross paths sooner with VSA/Dr. Bell to save him much misery.

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