Abstract | May 4, 2021
A Case report: Essential Thrombocythemia in Arterial Insufficiency related skin ulcer
Learning Objectives
- Describe the impact of thrombocytosis on peripheral arterial disease;
- Examine patients with arterial insufficiency ulcers;
- Identify risk factors that increase arteriothrombotic events.
Case Presentation:
74 year old Caucasian male with a past medical history of Essential Thrombocythemia, Hypertension, Peripheral arterial disease and chronic tobacco use disorder presents with a 10x8cm non-healing right lower extremity necrotic ulcer. The ulcer is hyperkeratotic with erythematous borders overlying the Achilles tendon. Nearly 10 months ago, a blister erupted, later ulcerating and forming an enlarging wound. He subsequently underwent bilateral atherectomies by vascular surgery. Patient’s Essential Thrombocythemia was treated by his hematologist with Hydroxyurea 200mg daily, leading to a platelet count of 450,000/ul prior to his procedure.
Post-procedure, Hydroxyurea was discontinued to allow for improved wound healing. He was eventually lost to follow up with podiatry, leading to progressive worsening of his wound and further limitations in his daily abilities. His pain became severe, prompting him to visit the Emergency Department. On arrival, his platelet count was markedly elevated at 1,949,000/ul, along with a leukocytosis and normocytic anemia. Diminished peripheral pulses were palpated on physical examination. Patient was initially started on broad spectrum antibiotics and full dose enoxaparin. His wound cultures grew Stenotrophomonas and he was switched to Trimethoprim/Sulfamethoxazole. Lower extremity arterial ultrasound showed monophasic waveforms.
Working diagnosis:
Infected Arterial Insufficiency Ulcer
Management:
Vascular surgery along with podiatry were consulted. Lower extremity aortogram with runoff showed significant stenosis of the femoral, popliteal and tibial arteries. Successful revascularization was completed via atherectomy, drug coated balloon therapy and placement of 2 EverFlex stents. Podiatric surgery subsequently performed incision and drainage of the wound followed by placement of an Achilles tendon graft. Patient was transferred to inpatient rehab for further ongoing care and therapy with a platelet count of 1,166,000 on dual anti-platelet therapy, Aspirin and Clopidogrel.
