Case Number : Case 1432- 18 December Posted By: Guest

The vesses shows intimal thickening, looks like hyaline arteriolosclerosis. Patient may have systemic hypertension or diabetes mellitus, or both. There´s also some dystrophic calcification of the vessel wall (Mönckeberg's arteriosclerosis).

Agree, vessels are markedly thickened so likely vascular ulcer.

Would do congo red to rule out amyloid. Also, wondered if there are some fungal profiles in the lumen on the last image. (probably not, but would do a PAS).  

Agree with Igor that these are changes observed clinically in a patient with an Ischemic/arterial type of ulcer. The histopathology shows changes seen in atherosclerosis and probably the patient has longstanding hypertension

Martorell's ulcer

Agre with ischemic leg ulcer, arterial thrombus-related.

Interesting, I was actually also wondering about calciphylaxis, but Martorell's ulcer probably is a clinically better fit. The dilemma made me do a quick google search and have come across this excellent article :

http://archderm.jamanetwork.com/article.aspx?articleid=421985

Authors propose that a number of previous case reports of PG on the leg might have been superficial biopsies of Martorell's ulcers which do resemble PG. Also learnt a new term 'Eutrophication' = Spontaneous and progressive dermatoliponecrosis.

Did ponder about calciphylaxis. But, usually small vessels are affected in the latter. Fits in better with an ischaemic/Martorell's ulcer.

Agree with Martorell's ulcer.

Agree with hypertensive ulcer.  I will add that the mucoid intimal thickening in the arterioles in picture 5 makes me think about malignant hypertension, as opposed to longstanding hypertension. 

Well done.  I suggested Martorell's ulcer based on the history of pain and these histological findings (calcific arteriolosclerosis and hypertensive arteriolopathy) which prooved to be the case.  He was a hypertensive non-smoker with no history of diabetes, renal disease or peripheral vascular disease. Angiograms ruled out large vessel arterial disease. A clinical clue is the anatomic location (laterodorsal leg or over achilles tendon) and that the ulcer is said to be disproportionately painful relative to it's size and is not releived by rest or elevation. The cornerstone of treatment is to control the blood pressure, analgesia and good wound care with antibiotics for secondary infection.  In this case the ulcer healed with some scarring over a period of 9 months.

Thanks to Dr Maulina Sharma and Dr Tom King for follow-up and references:

1. Martorell F. Las u´ lceras supramaleolares por arteriolitis de las grandes

hipertensas. Actas del Instituto Policlı´nico de Barcelona 1945; 1: 6–9.

2. Graves JW, Morris JC, Sheps SG. Martorell’s hypertensive leg ulcer: case report and concise review of the literature. J. Hum Hypertens 2001; 15:279-83.

3. Vuerstaek JD, Reeder SW, Henquet CJ, Neumann HA. Arteriolosclerotic ulcer of Martorell.  J Eur Acad Dermatol Venereol. 2010;24(8):867-874

4. Pinto, Ana Paula Frade Lima, et al. "Martorell's Ulcer: Diagnostic and Therapeutic Challenge." Case reports in dermatology 7.2 (2015): 199-206.

5. Hafner J, Nobbe S, Partsch H,  et al.  Martorell hypertensive ischemic leg ulcer: a model of ischemic subcutaneous arteriolosclerosis.  Arch Dermatol. 2010;146(9):961-968

6. Pacifico F, Acernese CA, Di Giacomo A. PGE(1) therapy for Martorell's ulcer. Int Wound J. 2011 Apr; 8(2):140-4.