frank100
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A 37 y/o man with papaplegia comes to the physician for a follow up examination. He has a decubitus ulcer over the sacrum that has not healed despite wound care and repeated debridemen over the past 3 months. Over the past 2 weeks he has had a low grade fever and a 3.6 kg weight loss. T: 38.1, bp: 120/80, examination shows a deep 4cm ulcer over the sacrum. Leucos: 14.000 (which is consistent with previous leucos count over the past month. Esr: 98.
Which of the following is the most likely diagnosis?
A) anaerobic infection.
B) malnutrition.
C) osteomyelitis.
D) squamous cell carcinoma.
E) type 2 diabetes mellitus
Edited by new_n_lost on 02/08/08 - 10:56 AM. Reason: All Caps r not Allowed
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| drk1980
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this one got me confused....
Osteomyelitis nidus could be the reason, despite reapeated debridement the ulcer does not heal.......moreover, a chronic non-healing ulcer may indicate development to Squamous Cell Ca.(Marjolins Ulcer). Also Poor Nutritional status is a factor contributing to chronicity of decubitus ulcers.
But taking labs into consideration, an isolated elevated ESR maybe eunff to Dx OMtis. opinions??
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| vnty
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Elevated ESR = non-specific but supportive evidence of osteomyelitis
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| mazinger
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Im also confused, so thats the main reason I didnt aswer it in the first place... Could be anything, agree with you vnty on that ESR is going to be increased, but is not also going to be increased in any type of inflammatory process?
Well I have many things that are not clear at this moment, so if anyone can explain this briefly.
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| frank100
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letīs try by elimination:
1.if it was type 2 dibetes, at least they could have given us (glucose levels). so it is not E.
2.it is posible, but a marjolin ulcer takes years to develop (iīm nnot saying that a marjolin ulcer wonīt develop in months, but it is not the common history). so D is not
3. anaerobic infection: yes, he could have had intermitent infections during that time (the sacrum is so close to dirty areas), that explains constant elevated WBC. BUT such intermitent infections where able to dig into the bone and cause osteomielytis (which is a more dangerous situation). thatīs why A can be, but is not my first choice.
4.malnutrition: if you have repeated infections in an ulcer for 3 months, that would decrease anyoneīs appetite. even mine, but if they want us to think in malnutrition, they could have given us the BMI or the albumin levels, etc... so thatīs why B is no my anwer.
so thatīs why I chose (c). sacrum osteomyelitis is very common in paraplegics, and is an emergency. Taking care of him quickly can save his or any other oneīs life.
maybe iīm wrong.
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| mazinger
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Your explanation sounds correct to me...
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| ujaala
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does osteomyelitis explains around 4 kg wt loss in 2 weeks?
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| yasmeen
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IT CAN B MALNUTRITION DEC PROTEIN INTAKE -- DEC IG --REPEATED INFECTIONS
DEC CALORIC INTAKE PLUS INFECTIONS---WT LOSS
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| fox
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| cerebral
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what about low grade fever for two weeks?and elevated ESR? malnutrition causes that?
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| Guptashutosh
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I think its NIDDM with secondary inf. , so the first step to mgt is to rule out NIDDM by RBS/FBS
so DM is the most likely ans
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| s2ckdeficient
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Osteomyelitis. Even if he did have diabetes mellitus, he has developed osteomyelitis. The deep ulcer is going through this epidermis, demis, subcutaneous, fascia right into the bone.
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| Aashi
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One Important point missed by everyone is the fact that malnutrition leads to delayed healing and also recurrent infections,and the fact that this pt has considerable amt of wt loss shldnt be ignored,and shldnt be surpassed commenting as infections --->decreased appetite,so its normal,thou this statement is partially right,I wouldnt agree completely to this..Nutritional support is of high priority for a bed ridden pt,and the fact that even with proper debridement and meds this infection kept coming back is coz, that he was recieving good amt of nutritional supprt from the hosp,and back home,he goes back on to the same lifestyle and cycle of infection and delayed healing continues....and abt ur q on low grade fever,and ESR,any infection causes a rise in ESR,and for osteomyelitis per se ,ESR is not used for intial dx testing,it is used for the follow up of treatment...so one cant be cent percent sure that this is a case of OM,just by looking at the ESR,coz its very nonspecific ,this dx shld have been supported with xray/bonescans/MRI,till then O.M will be only in the D/DX and not a cent percent DX,for this pt..,so with the given history ,and with support of the points i mentioned above----> I go for B as the main culprit for this guy recurrent infections..
GL 
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| radonc
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My answer is osteomyelitis. Need a high degree of suspicion because diagnosis is not straight forward.
Malnutrition explains why his pressure sore is not healing. However, it doesn't explain the inflammatory markers, fevers, raised ESR, and WCC.
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