A Man With Skin Ulcers After a Walk in the Woods

Richard Harold Flowers IV, MD; Nancy W. Shen; Preeya T. Shah, MD


July 28, 2023

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


An 81-year-old man who lives in Washington State presents to the dermatology clinic in the spring for evaluation of bilateral nonhealing ulcers on his legs. He reports that he cut his left leg on a branch while hiking in the woods 2 months earlier. A few weeks after the initial injury, he noticed multiple small, weeping nodules on his legs. The lesions have continued to increase in number since that time. Courses of clindamycin and then doxycycline for suspected abscesses did not result in significant improvement.

His past medical history is significant for type 1 diabetes mellitus, hypertension, venous insufficiency, and deep venous thrombosis (DVT) in his right leg. He takes apixaban daily because of his history of DVT, as well as insulin for type 1 diabetes.

The patient reports intermittent pruritus and pain at the site of the lesions. Since their onset, he has had no fevers, chills, weight loss, joint pain, or fatigue. He lives with his wife and two dogs. He has no other pets and has no recent history of travel or changes in medications.


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