Recalcitrant Leg Ulcers as the Only Manifestation of Essential Type 2 Cryoglobulinemia

Chronic leg ulcers are persistent conditions that might be a diagnostic and therapeutic challenge, with great impact in health care costs and patients’ quality of life. We report a case of a 60-year-old woman, with long-lasting recalcitrant leg ulcers, which led to left leg amputation 10 years ago. Several attempts to heal the right leg were made, including skin grafting in three different occasions and several surgical debridements, all with unsatisfactory outcome. Some months before the ulcers began, the patient had been diagnosed with undifferentiated connective tissue disease because of arthralgia and positive antinuclear antibodies, therefore low dose systemic corticosteroids and azathioprine were prescribed. For the last 4 years she has been followed in our department and since then no evidence of clinical or laboratorial criteria for autoimmune diseases was found, thus the immunosuppressive therapy was stopped. She maintained ever since a high rheumatoid factor but without other evidence of autoimmune disease. Medical history was otherwise irrelevant. Several cutaneous biopsies were performed, with no evidence of malignancy or vasculitis. Recently, cryoglobulins became positive, with type 2b cryoglobulin identification on immunofluorescence. Serology for Hepatitis C virus was consistently negative, hence an Essential type 2 Cryoglobulinemia diagnosis was established. No renal impairment, vascular purpura, arthralgia or arthritis was found. The authors emphasize the importance of considering less common etiologies for chronic leg wounds, even in the absence of other suggestive symptomatology, as well as the pertinence of reconsidering diagnosis in highly suspect cases.

Leg Ulcers in Antiphospholipid Syndrome Secondary to Systemic Lupus Erythematosus Treated with Intravenous Immunoglobulin

BACKGROUND: Despite encouraging reports on the efficacy of intravenous immunoglobulin (IVIg) in antiphospholipid syndrome, the clinical value of this treatment is not well established, and most of the data are based on case reports and small series of patients. OBSERVATION: We describe the significant improvement of leg ulcers with IVIg in a 61-year-old female, with diabetes mellitus, venous peripherical insufficiency and secondary antiphospholipid syndrome to systemic lupus erythematosus. CONCLUSIONS: This case illustrates a rare cause of leg ulcers and documents that IVIg may be an effective adjuvant treatment in the management of selected patients with antiphospholipid syndrome when conventional strategies using subcutaneous heparin and low-dose aspirin are insufficient.

Úlceras de Perna em Portugal: um Problema de Saúde Subestimado

To determine the prevalence and aetiology of leg ulceration in a population of patients registered with five health centres within Lisbon, a study was undertaken to identify patients receiving care from community and hospital. Identification of patients was through health professionals, with a simple questionnaire completed for all patients identified who were registered with the five health centres. In 263 patients were identified in a population of 186,000 (total prevalence 1.41/1,000 population). The prevalence was similar between men and women (1.3 and 1.46/1,000, respectively). As expected this was highly age dependent, being most common in patients aged over 80 years (6.5 and 4.9/1,000, respectively). The ulceration was highly chronic in nature, with median ulceration of 18 months. Of the 240 with ulcer duration recorded, 158 (66%) had the present ulcer for longer than one year, and 40 (17%) for longer than five years. The cause of ulceration was unknown to the health professional treating the patient in 86 (33%) of the cases. Of those with a cause, most commonly this was venous (80%) with 10% mixed arterial/venous ulceration and 3% frank arterial disease. Most care was provided by community services, with 145 (55%) treated in health centres and 77 (29%) treated in the patient's home. The mean number of treatments per week was 3.0, with 21 (9%) of patients being seen on a daily basis. Most patients (80%) had seen a specialist doctor for their ulceration, most often a dermatologist (48%) and a vascular surgeon (33%). The prevalence of chronic leg ulceration is similar to other reported studies in western Europe, and indicates that approximately 14,000 patients suffer from leg ulceration at any one time in Portugal. This produces a high burden on both hospital and community services.

Consulta de Úlcera de Perna do Hospital de Santa Marta

Leg ulcers constitute a highly prevalent pathology in society, and are particularly common in the Angiology and Vascular Surgery outpatient clinic. The prevalence of these patients in this Department result from the fact that 70% of them display superficial and/or deep venous insufficiency of the lower limbs. To address this problem and optimize the therapeutic approaches available to the Chronic Leg Ulcer (CLU) patients, the Department of Angiology and Vascular Surgery has created, in March 2005, an appointment specific to CLU patients. An evaluation protocol was developed, including ulcer characterization, standardization of the conservative treatment, followed by surgical intervention, whenever required. The results obtained were evaluated 18 months after the onset of this protocol. Analysis of the results revealed that the majority of the patients responded positively to the new therapeutic approach, with closure of the ulcer in 43% of the patients and a significant improvement detected for an additional 30%. Furthermore, it was observed that a detailed evaluation of these patients should be regarded as a whole, followed by a standardized and targeted approach, resulting in a particularly successful approach on the treatment of this pathology.

Úlceras de Perna. Opções Diagnósticas e Terapêuticas

As úlceras de perna são uma doença frequente, causadora de grande morbilidade, cujo diagnóstico é por vezes difícil. Dele depende a terapêutica que quando não adequada pode levar a situações graves com risco de amputação. Os autores descrevem as bases que permitem um diagnóstico simples destes quadros assim como a terapêutica médica mais habitual, focando a sua atenção no tratamento local destas lesões.

Úlceras de Perna - Boa Resposta ao Tratamento com Matriz de Colagénio, Celulose Regeneradora Oxidada e Prata

A maior compreensão da fisiopatologia das úlceras de perna tem permitido o desenvolvimento de novas modalidades terapêuticas. As matrizes constituídas por colagénio e celulose regenerada oxidada permitem, através da ligação a proteases, menor degradação da matriz, protecção e estabilização de factores de crescimento favorecendo a cicatrização da úlcera. Doente do sexo masculino, 72 anos de idade, com síndrome metabólica e insuficiência veno-arterial periférica, com úlceras, extensas, de longa evolução, refractárias aos inúmeros tratamentos efectuados, curadas com pensos com matriz de colagénio, celulose regenerada oxidada e prata.

Epilepsy and Physical Exercise

Epilepsy is one of the commonest neurologic diseases and has always been associated with stigma. In the interest of safety, the activities of persons with epilepsy (PWE) are often restricted. In keeping with this, physical exercise has often been discouraged. The precise nature of a person’s seizures (or whether seizures were provoked or unprovoked) may not have been considered. Although there has been a change in attitude over the last few decades, the exact role of exercise in inducing seizures or aggravating epilepsy still remains a matter of discussion among experts in the field. Based mainly on retrospective, but also on prospective, population and animal-based research, the hypothesis that physical exercise is prejudicial has been slowly replaced by the realization that physical exercise might actually be beneficial for PWE. The benefits are related to improvement of physical and mental health parameters and social integration and reduction in markers of stress, epileptiform activity and the number of seizures. Nowadays, the general consensus is that there should be no restrictions to the practice of physical exercise in people with controlled epilepsy, except for scuba diving, skydiving and other sports at heights. Whilst broader restrictions apply for patients with uncontrolled epilepsy, individual risk assessments taking into account the seizure types, frequency, patterns or triggers may allow PWE to enjoy a wide range of physical activities.

Onychomycosis in Patients with Chronic Leg Ulcer and Toenail Abnormalities

Nails have a limited number of reactive patterns to disease. Accordingly, toenail changes of different etiologies may mimic onychomycosis. OBJECTIVE To determine the prevalence of toenail onychomycosis among patients with leg ulcer and toenail abnormalities attending a dermatology clinic. METHODS A cross-sectional study was conducted through the analysis of clinical records and results of mycological examination. RESULTS A total of 81 patients were included, with a median age of 76.0 years. Most ulcers were of venous etiology, followed by those of mixed and arterial pathogenesis. The mycological evaluation confirmed the diagnosis of onychomycosis in 27.2% of the patients. The etiologic agent was a dermatophyte in 59.1% of isolates in nail samples, while Trichophyton interdigitale was the most frequent fungal species (40.9%). CONCLUSIONS Most toenail abnormalities in patients with chronic leg ulcer were not onychomycosis. This study highlights the importance of systematic mycological examination in these patients, in order to avoid overtreatment with systemic antifungals, unnecessary costs and side effects.

Involuntary Rhythmic Leg Movements Time-Locked With the Respiratory Cycle

Involuntary rhythmic leg movements in childhood is an uncommon condition, the generators of which remain unknown. We report on a male 3 years of age with distinct features providing important clues concerning the location of one of these generators. At the age of 7 months, the previously healthy young male started with low frequency, rhythmic, and continuous (both during wakefulness and sleep) flexion/extension movements of the lower limbs. Movements interfered significantly with gait acquisition, and, despite normal cognitive development, he was able to walk only at age 2 years, 4 months. The neurologic examination revealed the absence of automatic stepping in the neonatal period, but was otherwise normal. A polygraphic electroencephalogram/electromyogram EEG/EMG) recording, at the age of 2 years, 9 months, revealed rhythmic and synchronous legs with EMG activity at 0.5 Hz. A more complete polygraphic recording at the age of 3 years, 10 months, showed a lower frequency (0.35 Hz) for the movements, which were time-locked with the respiratory cycle. Magnetic resonance imaging (MRI) of the brain revealed an increased T2 signal in the upper medulla-lower pons regions. The generator of the rhythmic legs movements is postulated to be the respiratory center, connecting with the reticulospinal projecting neurons through an aberrant pathway.