Chronic Leg Ulcer in Diseases of the Blood

By BENJAMIN R. GENDEL, M.D. C HRONIC LEG ULCERS have been described as a complication of several diseases of the blood and are best known in association with sickle cell anemia. Diggs and Ching1 reported that chronic ulcers or scars of old ulcers were present in 75 per cent of adults with this disease. However, it is less commonly appreciated that other diseases of the blood may present the complication of chronic leg ulcer. In 192-5, G#{228}nsslen’ mentioned a 19 year old patient with congenital (hereditary) hemolytic anemia who, over a period of nine months, had recurrent leg ulcers which resisted therapy, but healed eight days after splenectomy. Since that time over twenty patients with hemolytic anemia have been reported with chronic leg ulcers. The exact incidence of this complication is difilcult to determine, but Vaughan3 described the occurrence of leg ulcers in three patients of a series of i8 with congenital hemolytic anemia. Taylor4 reported one patient with leg ulcer among 43 patients with hemolytic anemia. The combined incidence for the complication of leg ulcer in these two series is 6.5 per cent. Following the report of Taylor which summarized the previous literature, two cases were reported by Leger and Orr’ and another by McGovern.6 The ulcer complicating hemolytic anemia occurs in younger people and is located on the lower one-third of the legs. Ulcers were usually several centimeters in diameter and were surrounded by an area of pigmented skin. In half the cases, the ulcers were bilateral. In the majority of instances healing occurred rapidly after splenectomy, although the lesions proved refractory to previous therapeutic efforts. Several French authors7’ 8 have noted the association of chronic leg ulcer with splenomegaly. The diagnosis in their cases is not clear, but they seem to represent patients with Banti’s syndrome of congestive splenomegaly because leukopenia and recurrent hematemesis were present. Witts9 reported two patients with idiopathic thrombocytopenic purpura complicated by indolent leg ulcers. His first patient was a 2-1 year old female with thrombocytopenic purpura of nine years’ duration. Six years earlier an ulcer appeared on the left leg which did not heal for two years. Subsequently an ulcer appeared on the right leg, but healed in less time. Both remained healed thereafter. The second patient, a 2-6 year old man with a lifelong history of excessive bruising and bleeding, had chronic leg ulcer for eight or ten years. The weight of the spleen removed at operation was 12-2Gm. In this case there was no improvement of either the general condition or the leg ulcer after splenectomy. Witt also stated that leg ulcers occurred in Gaucher’s disease. The unique occurrence of leg ulcer in pernicious anemia was reported by Lasch.’#{176}