Leg ulcer in SCD patients

Case: 32 years old African-American female with a known history of Sickle Cell Disease (SCD) getting recovered in ICU from a Sickle cell crisis and complained of severe leg pain; on examination found to have a painful ulcer site. Venous duplex is negative. Your next step?

A) Prophylactic antibiotic

B) IVC filter

C) Workup for pulmonary hypertension (P-HTN)

D) Lower Extremity angiogram

Answer: C

This question aims to highlight that leg ulcers in SCD patients are highly associated with morbidities like Deep Venous Thrombosis (DVT) and P-HTN.

Leg ulcer in SCD patients is usually not an infectious process. It requires good wound care. There is no need for prophylactic antibiotics (choice A).

IVC filter is not the first line of management in DVT, so inserting a prophylactic IVC filter (choice B) is unnecessary.

A lower extremity angiogram can be pursued if there is a threat to limb viability. This should not be the 'next best action of management' (choice D).

Leg ulcers in SCD patients are way more painful than in other patients. This is one of the characteristics of leg ulcers in this patient population.

If the venous duplex is negative, wound care, pain management, topical opioids, lower extremity elevation, and compression bandages usually suffice. In unresolved cases, surgical debridement may be needed.

#hematology

#pulmonary

#dermatology

References:

1. Gladwin MT, Sachdev V, Jison ML, Shizukuda Y, Plehn JF, Minter K, Brown B, Coles WA, Nichols JS, Ernst I, Hunter LA, Blackwelder WC, Schechter AN, Rodgers GP, Castro O, Ognibene FP. Pulmonary hypertension as a risk factor for death in patients with sickle cell disease. N Engl J Med. 2004 Feb 26;350(9):886-95. doi: 10.1056/NEJMoa035477. PMID: 14985486.

2. Gordeuk VR, Castro OL, Machado RF. Pathophysiology and treatment of pulmonary hypertension in sickle cell disease. Blood. 2016 Feb 18;127(7):820-8. doi: 10.1182/blood-2015-08-618561. Epub 2016 Jan 12. PMID: 26758918; PMCID: PMC4760088.