No abstract

A 77-year-old woman presented with a 4-week history of painful ulceration on her left calf. The skin had previously been normal, and there was no history of trauma. The patient had a history of ischaemic heart disease, type 2 diabetes, hypertension and atrial fibrillation. Her medication on admission included furosemide, enalapril, felodipine, warfarin, metformin, nebivolol and glargine.On examination, a well-defined ulcer with a violaceous border and central eschar formation was seen (Fig. 1a). Peripheral pulses were easily palpable despite bilateral pitting oedema to the knees. Ankle brachial pressure index was 1.1 (right) and 0.9 (left) with triphasic signals. There were no varicosities, and peripheral sensation was intact. The patient was apyrexial and had a body mass index of 37. The remainder of the examination was normal. Blood tests on admission gave normal results for renal, haematological, liver, bone, thyroid function and vasculitic screen. Further blood tests revealed low levels of phosphorous (0.7 mmol ⁄ L; normal 0.8-1.6), magnesium (0.63 mmol ⁄ L; 0.7-1.0) and vitamin D (8.7 ng ⁄ mL; 16-74), raised parathyroid hormone (PTH) level (7.3 pmol ⁄ L; 1.6-6.9), and normal 1,25 dihydroxycholecalciferol level (24 pg ⁄ mL; 20-50). Serum corrected calcium, calcium phosphate product, urinary calcium and 24-h urinary calcium were within the normal range. Further imaging excluded an underlying malignancy.The patient was admitted to hospital for bed rest with leg elevation to reduce the leg oedema. Antibiotics were given empirically for possible concomitant infection of the ulcerated area. Despite this treatment the disease progressed, and she required increasing amounts of analgesia. On day 16, she developed a further area of reticular discoloration on the right lower leg, which subsequently became necrotic (Fig. 1b). Histopathological findingsTwo biopsies were taken from different sites of the ulcer on the left leg. One biopsy was consistent with venous stasis disease. The other showed calcified arterial walls with haemorrhage deep in the reticular dermis and subcutis, with no evidence of vasculitis (Fig. 1c).

No abstract