Mr. K, a 34-year-old Caucasian, presented to his primary care physician (PCP) in May 2015 with multiple, painful, partially dried black nodular plaques surrounding the lower portion of his right leg (see Figure 1). Per his medical chart, these lesions would originate as erythematous purple lesions and develop into ulcers with serous exudate and then form escharotic plaques. His past medical history included uncharacterized vasculitis process, arterial thrombosis since 2008 that required bypass grafts, and peripheral arterial disease. The CT scan of his abdomen showed a partially occluded right external iliac and common femoral, superficial femoral, and popliteal arteries, with polytetrafluoroethylene grafts and vascular stents in both extremities. Mr. K had developed pseudoaneurysms of the anterior tibial artery and multiple bouts of cellulitis of his right leg. Ehlers-Danlos syndrome (an inherited disorder of the connective tissues) was deemed a possible diagnosis, but all current tests of possible connective tissue diagnoses yielded no results; as of publication, Mr. K not been provided a diagnoses for the cause of arterial failure in his legs.
After 2 years of recurrent nodular plaques to his lower legs, differential diagnoses of vascular ulcers, infection, phlebitis, or possible rheumatologic condition/inflammation were explored. As part of the differential diagnosis, Mr. K was referred to a rheumatologist who requested testing for possible TB: Mr. K had a remote history of traveling to Latin America during his childhood to countries with a known elevated prevalence of the disease. In addition, several extended antibiotic treatments including amoxicillin/clavulanate, sulfamethoxazole trimethoprim, clindamycin, and doxycycline had been previously prescribed for these same nodular appearances with intermittent positive results.
The diagnosis of CTB was confirmed after 2 positive Quantiferon Gold tests,17 an in vitro testing method approved by the United States Food and Drug Administration. Chest x-rays were found to be negative, as were HIV, rheumatoid factor, and antinuclear antibody screening tests. Following the diagnosis, the state health department directly observed daily therapy that included a multidrug TB medication regimen of pyrazinamide (500 mg oral tablet, 1500 mg per day), rifampin (600 mg intravenous injection daily), ethambutol (400 mg oral tablet, 1200 mg per day), and isoniazid (300 mg oral tablet daily). Vitamin B6 also was prescribed, but the dosage was not available in the medical record.
Mr. K was provided a wound care consult to the author’s Outpatient Physical Therapy Clinic by his PCP because of continued ulcer formation on his lower right leg and increasing pain on the dorsal surface of his right foot that was limiting ambulation. Mr. K required long-term anticoagulation with warfarin (5 mg oral tablet) with a therapeutic goal to reduce the risk of future deep vein thromboses because his INR range was 2.0 to 3.0. He continued weekly visits to his PCP for pain management and for active treatment of concomitant cellulitis to the same area as the wounds. Sulfamethoxazole trimethoprim (800 mg/160 mg oral tablet) was provided daily. The introduction of Mtb medication increased INR levels to 6.2, and warfarin intake had to be adjusted weekly.
Biweekly wound care visits were completed in a negative pressure room; the lesions produced minimal to moderate drainage, increasing the possibility of aerosolization during wound cleansing and debridement.10 N95 masks were worn by physical therapists throughout wound care sessions; the treatment table and chairs that came in contact with Mr. K were cleaned with bleach (0.55% sodium hypochlorite) for the mandatory 3-minute period (per hospital and product guidelines) for documented kill rate of any possible aerosolized TB bacilli.
Initially, Mr. K reported increased pain when the ulcers were drained; tactile examination had to be terminated because manipulation of the ulcer borders using cotton-tipped applicators also increased his pain level. On subsequent PT wound care visits, Mr. K was premedicated with oxycodone as prescribed by his PCP, with eventual dosage of 80 mg per day for pain tolerance; wound care providers requested the addition of 4% lidocaine solution to apply to right leg 10 to 15 minutes before treatment to desensitize his skin and permit gentle sharp debridement of his wounds (see Figure 2). In addition to lesions on the entire leg distal to his knee, a Stage 2 pressure injury was identified under the first metatarsal head of his right foot.
During the second week of wound care treatment, Mr. K presented with a full body rash. The Chief Medical Officer of the Health Department opted to stop all TB medication for 2 weeks as a precaution for a possible allergic reaction to one of the medications. In addition, Mr. K’s PCP prescribed amoxicillin/clavulanate (875 mg/125 mg oral tablet every 12 hours). The TB regimen was restarted after 14 days as the rash subsided, and no further reactions were present for the duration of the wound care treatments.
Throughout the wound care visits, Mr. K’s ulcers were cleansed thoroughly with Skintegrity Wound Cleanser (Medline Industries, Mundelein, IL). Mechanical debridement of nonstable necrotic tissue and slough, determined through visual and tactile examination, was performed using cotton-tipped applicators and tweezers as able. Cavilon No Sting Barrier Film swab (3M, St Paul, MN) was applied to the perimeter of all ulcers, followed by collagen (Puracol, Medline Industries) and silicone-bordered bandages (Aquacel Foam; ConvaTec, Greensboro, NC) for ease of dressing removal and periwound protection. The same technique was used for the Stage 2 pressure injury under his right first metatarsal head.
To address potential spread of the bacteria, the wounds were completely covered between dressing changes to reduce environmental contamination and provide additional support to primary dressings. Because aerosolization of wounds likely could occur due to use of wound cleanser, Mr. K initially was treated in negative pressure room as previously noted. However, care subsequently moved to a regular wound care clinic; the Infection Control Officer of the facility deemed Mr. K of minimal risk to others as long as no patients were scheduled and treated in the wound care room for 2 to 3 hours after his visit. As a precaution, no further treatments were conducted for a minimum of 12 hours.
Mr. K used crutches for nearly the entire duration of open ulcers and remained as nonweight-bearing as possible. Over a period of 40 days, Mr. K was seen by physical therapists 10 times and then twice weekly until the wounds resolved (see Figure 3). He self-limited pain medication as the wounds progressed and he was weight-bearing ~2 weeks into treatment, initiating full weight-bearing for short distances. At the time of discharge, Mr. K had stopped the pyrazinamide and ethambutol; he continued the isoniazid and rifampin for the full 9-month term prescribed by the state health department. The combination of adhering to the medication regimen, being provided appropriate pain control by his PCP, and maintenance of wound care follow-up facilitated resolution of the lesions in <60 days.