Search Results
Merkel Cell Carcinoma of the Lower Extremity
A Case Report
Merkel cell carcinoma is a rare, often fatal, neuroendocrine cutaneous malignancy with a highly variable clinical presentation. Due to the rapid progression of the disease, early detection and treatment is vital to survival. Here, we report the case of a 45-year-old woman whose podiatrist noticed an unusual lesion on her lower left leg and referred her to a dermatologist for work-up. A diagnostic excisional biopsy confirmed the diagnosis and was followed by treatment that included wide local excision of the primary lesion with subsequent chemotherapy and radiation. At the time of diagnosis, sentinel lymph node biopsy was positive. Due to the increasing prevalence of Merkel cell carcinoma in the past decade and its propensity to present on the lower extremity, podiatric physicians need to be aware of the clinical presentation and treatment guidelines for this elusive disease.
Malreduction of a distal fibular fracture can lead to degenerative changes in the ankle joint. Previous studies have shown that the selective use of various fibular reconstructive osteotomies may halt the progression of degenerative arthritis by restoring the normal tibiotalar contact area and decreasing the stresses on the articular cartilage. In this case report, we achieved alignment with restoration of the talocrural angle and Shenton's line of the ankle using a transfibular osteotomy and an allogeneic fresh-frozen femoral head graft to fill the resultant defect. The advantage of this procedure is twofold. First, fibular-lengthening procedures may potentially decrease the eventual need for joint-sacrificing procedures such as an arthrodesis or arthroplasty. Second, an allograft allows for larger deficit correction without concern for donor-site morbidity. To our knowledge, this is the first case report using a fresh-frozen femoral head allograft for a fibular-lengthening osteotomy in the podiatric medical literature. Further research with larger patient populations is needed to establish whether fresh-frozen femoral head allograft is a reliable graft option for fibular-lengthening procedures.
Acral lentiginous melanoma (ALM) is a disease that is found on the palms, soles, and nail beds. Because these areas are not often examined during general medical examinations, the presence of ALM often goes unnoticed or the diagnosis is delayed. Research shows that the misdiagnosis of ALM is common, reported between 20% and 34%. We present three cases of ALM that were initially misdiagnosed and referred to the senior author (B.C.M.) in an effort to assess why misdiagnosis is common. The existing literature illuminates clinical pitfalls in diagnosing ALM. The differential diagnosis of many different podiatric skin and nail disorders should include ALM. Although making the correct diagnosis is essential, the prognosis is affected by the duration of the disease and level of invasiveness. Unfortunately, most of the reported misdiagnosed cases are of a later stage and worse prognosis. This review highlights that foot and ankle specialists should meet suspect lesions with a heightened index of suspicion and perform biopsy when acral nonhealing wounds and/or lesions are nonresponsive to treatment.
Pseudogout of the First Metatarsophalangeal Joint Associated with Hallux Valgus
An Atypical Bilateral Case
Calcium pyrophosphate dihydrate crystal deposition disease has various clinical features, and pseudogout is one of the six clinical forms. Chondrocalcinosis is the term used to describe the radiographic appearance of the disease. A review of the literature revealed that the appearance of this type of arthropathy in the foot is infrequent. We offer a review of the disease and report an atypical bilateral case of pseudogout in a patient 56 years of age without a history who presented with symptoms of arthritis localized in the first metatarsophalangeal joint associated with hallux valgus and was treated surgically. Radiographic evaluation of the feet did not reveal signs of chondrocalcinosis. The patient had no metabolic abnormalities, except for high uric acid values. Chemical analysis of the surgical samples demonstrated the presence of calcium pyrophosphate dihydrate crystals, confirming the diagnosis. We believe that arthropathy by deposition of calcium pyrophosphate dihydrate in the foot, although rare, must be considered in the podiatric physician’s differential diagnosis when a patient presents with articular pain in the foot associated or not with deformities. (J Am Podiatr Med Assoc 100(2): 138–142, 2010)
Group B and F Beta Streptococcus Necrotizing Infection–Surgical Challenges with a Deep Central Plantar Space Abscess
A Diabetic Limb Salvage Case Report
We present the case of a 66-year-old, type II diabetic male with a deep wound to the plantar-lateral aspect of his right hallux. On examination, the central plantar compartment of his right foot was moderately erythematous and tender on palpation. After obtaining a deep wound culture, treatment was complicated by a progression of a group B and F beta streptococcus, necrotizing infection. The patient underwent a right hallux amputation, followed by a plantar medial incision for drainage of an abscess to the medial and central plantar compartments of the foot. Due to the extent and limb threat of the infection, the patient ultimately underwent a transmetatarsal amputation. Advanced healing modalities were also employed to decrease wound healing times, which allowed the patient to achieve early weightbearing and return to activities of daily living. This study depicts how the astute podiatric surgeon needs to make a decision in a timely manner to surgically debride all nonviable and necrotic tissue in order to minimize further amputation and preserve foot function.
Background:
Since 2006 there have been increased reports of severe agranulocytosis and vasculitis associated with levamisole use. Historically, levamisole was an immunomodulatory agent used in various cancer treatments in the United States. Currently the drug is used as an antihelminthic veterinary medication, but it is also used as an additive in freebase cocaine. There are multiple reports of levamisole-induced vasculitis in the head and neck but limited reported cases in the lower extremities. This article describes a 60-year-old woman who presented to the emergency department with multiple painful lower-extremity ulcerations.
Results:
Radiographs, laboratory studies, and punch biopsy were performed. Physical examination findings and laboratory results were negative for signs of infection. Treatment included local wound care and education on cocaine cessation, and the patient was transferred to a skilled nursing facility. Her continued use of cocaine, however, prevented her ulcers from healing.
Conclusions:
Local wound care and cocaine cessation is the optimal treatment for levamisole-induced lesions. With the increase in the number of patients with levamisole-induced vasculitis, podiatric physicians and surgeons would benefit from the immediate identification of these ulcerations, as their appearance alone can be distinct and pathognomonic. Early identification of levamisole-induced ulcers is important for favorable treatment outcomes. A complete medical and social history is necessary for physicians to treat these lesions with local wound care and provide therapy for patients with addictions.
This article reports on a 45-year-old woman who presented with pruritus and was diagnosed as having chigger mite infestation, a rare condition. The chigger mite larvae were encountered while the patient was traveling in South America. A small erythematous area with a well-circumscribed papule in the sulcus of the second digit of the right foot was incised and drained. Follow-up examination showed relief of all symptoms, including pain and pruritus. This unusual case presentation underscores the need for all podiatric physicians to obtain a comprehensive history, including history of travel, along with performing a thorough physical examination. (J Am Podiatr Med Assoc 93(5): 399-401, 2003)
We report an unusual case of Aeromonas hydrophilia septicemia in a nonmobile diabetic patient secondary to contaminated well water used for bathing with a portal of entry through chronic forefoot and heel ulcers. To date, there are no documented cases similar to this patient's presentation. Aeromonas hydrophilia is commonly distributed among aquatic environments and tends to be found during warmer months. It is a rare cause of disease but can be life threatening and deadly, as in our case, in immunocompromised individuals. As podiatric physicians, we must remain diligent and have a high index of suspicion to identify patients at risk for this rare but serious infection and administer treatment aggressively to limit morbidity and mortality.
This case study presents a 72-year-old male patient who presented with multiple schwannomas. The patient underwent several soft-tissue mass excisions performed by general surgery and podiatry. The physical examination displayed multiple nodules on the left foot, ankle, and previously in the groin. Magnetic resonance imaging displayed high–T2-weighted signal masses in the left plantar heel and ankle. These masses were excised and, through pathologic analysis, were diagnosed as schwannomas. Immunohistochemistry displayed a mosaic pattern of INI1 expression, a gene associated with tumor suppression. The patient demonstrated findings consistent with multiple schwannomas (eg, schwannomatosis or neurofibromatosis type 2). Because of the patient's medical history, neurofibromatosis type 2 was more probable.
Swelling of the leg is a frequent finding in podiatric medicine. Unless the patient draws notice to the condition or the physician is diligent in asking questions and examining the extremity, the condition may be viewed as minor and given little attention. Swelling of the leg can be a clinical sign of certain systemic diseases, lymphatic and venous disorders, or other miscellaneous causes. Dermatologic consequences linked to many of these causes of swelling are well documented. What is not as well chronicled is a dramatic skin alteration associated with chronic lymphedema. This article provides an overview and a case presentation of the unusual and debilitating skin condition related to chronic lymphedema of the lower extremity known as elephantiasis nostras verrucosa. (J Am Podiatr Med Assoc 96(5): 442–444, 2006)
