Case Report

A 60-year-old man with past medical history of hypertension, post-traumatic stress disorder, major depression, hepatic steatosis, chronic kidney disease, and untreated hepatitis C virus (genotype 1b) initially presented to the outpatient primary care clinic with a chief complaint of an extremely painful right lower extremity ulcer that had developed and grown progressively larger after mild trauma against a metal corner 4 months prior to the appointment. He admitted to picking at the granulation tissue that would develop over the ulcer. He was treating the ulcer with antibiotic ointment. On initial exam, the ulcer was about 2x2 cm, located a few inches above the ankle on the lateral right leg, and associated with some lower extremity edema. His primary care physician was concerned at the time for a venous stasis ulcer. Initial plain films of the leg were obtained, and these did not show any evidence of osteomyelitis. A lower extremity doppler ultrasound did not reveal a deep vein thrombosis that could account for the edema. He had no signs of heart failure, ascites, or volume overload otherwise. He was referred to podiatry and wound care.