Persistent Lower-Limb Ulcers in a Patient with Diabetes.

Previously published Photo Quizzes are now featured in a mobile app. Get more information at http:// www.aafp.org/afp/apps. A 60-year-old woman presented with enlarging ulcers on her ankle and foot. Despite treatment, the ulcers worsened and became more painful, and she noted a new ulcer on her left shin. The problem started as a small ulcerated lesion on the lateral dorsal area of her foot that had developed two years earlier after she bumped into a dresser. She had a history of diabetes mellitus, hypertension, hyperlipidemia, and myeloproliferative disease. At the time of presentation, her medications included enalapril (Vasotec), metoprolol, furosemide (Lasix), fenofibrate (Tricor), insulin aspart (Novolog), insulin detemir (Levemir), metformin, prednisone, dapsone, topical silver sulfadiazine (Silvadene), and clobetasol cream (Temovate). She was previously taking hydroxyurea and anagrelide (Agrylin) for her myeloproliferative disease. She was a nonsmoker. On examination, she was afebrile and had ulcers of varying size on her left lower leg over the lateral malleolus and foot (Figures 1 and 2). There were larger ulcerations exposing muscles and tendons, with sharp margins, an undermined and violaceous border, and granulation tissue over the ulcer beds. A smaller area of ulceration was noted in the left midpretibial area. A complete blood count revealed a white blood cell count of 17,200 per mm3 (17.2 × 109 per L). Her blood glucose level was 126 mg per dL (7.0 mmol per L). Findings from Doppler ultrasonography and wound cultures were unremarkable.