Mark Crislip, MD


June 29, 2011

Clinical Presentation

A 28-year-old man presents from jail with chronic cellulitis of the leg with an ulcer.

History and Physical Examination

History. The patient has a 3-month history of a nonhealing ulcer on his leg. It started as a red bump that evolved into a chronic ulcer. The ulcer is currently the size of a quarter and has grown from dime size. It is moderately painful. While in jail, he was given a course of cephalexin and ciprofloxacin with no change in the ulcer. He denies any fever, chills, or rigor and has been gaining weight on a typical incarceration diet. The rest of the review of systems is negative.

  • Past medical history: none

  • Medications: none

  • Allergies: none

  • Habits: has smoked 1 pack per day since age 12

  • Pets: none; lived on a farm until 12 months ago

  • Diet: regular

  • Travel: recently came from Panama; he walked/hitchhiked to the Mexican border over the last year; the red bump started when he was in Costa Rica

  • Social: heroin user (uses legs and arms), illegal immigrant, and failed drug smuggler, all of which have led to his current situation

  • Immunizations: none

  • Sports/water exposure: waded and swam in many Central American rivers and lakes

  • Infectious disease exposure: grew up on a goat/cow farm; several family members could have had tuberculosis (TB), but this was unclear from the patient's history; drank raw goat's and cow's milk; suffered innumerable bug bites and minor environmental trauma as he trekked north

Physical examination. On physical examination, the following were noted:

  • Vital signs: temperature. 97.5 °F; pulse, 80 beats/min; respirations, 12 breaths/min; blood pressure: 110/76 mm Hg

  • General: not ill appearing

  • HEENT: normal; no adenopathy

  • Lungs: clear

  • Heart: no murmurs, rubs, or gallops

  • Abdomen: normal without hepatosplenomegaly

  • Extremities: right leg has a quarter-sized ulcer with heaped up borders and surrounding erythema (Figure); the right leg was slightly edematous compared with the left; no diffuse erythrodema

  • Skin: otherwise normal

Figure. Leishmaniasis ulcer on a left forearm, similar to the case described here. Public domain, Wikimedia Commons.

Diagnostic Evaluation

Lab results. The following results were obtained:

  • WBC: 9.7 x 103/mm3

  • Hgb: 10.2 g/dL

  • Differential: normal

  • Bilirubin: 0.9 mg/dL

  • Transaminases: normal

  • Urinalysis: normal

  • Swab of ulcer grew Staphylococcus aureus and Group A Streptococcus


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