75 VOL. 48 NO. 4 2014 ACTA MEDICA PHILIPPINA An Immunocompromised Male with a Chronic Wound _______________ Corresponding author: Agnes D. Mejia, MD Department of Medicine Philippine General Hospital University of the Philippines Manila Taft Avenue, Ermita, Manila 1000 Philippines Telephone: +632 5548400 local 2200/2206 Telefax: +632 5264372 Email: agnesmejiamd@gmail.com A Case of a 39-year-old Immunocompromised Filipino Male with Non-Healing Wound of the Right Lower Leg Janice Jill K. Lao, Tennille S. Tan, Alex P. Bello, Malen Uichangco-Bravo, Emily Ruiz-Jacinto, Allan D. Corpuz and Agnes D. Mejia Department of Medicine, College of Medicine and Philippine General Hospital, University of the Philippines Manila Case A 39-year-old Filipino male was diagnosed with SLE in 2006 (3 years prior to admission), presenting with hypertension, on-and-off bipedal edema, headache, malar and discoid rash, oral ulcers, arthralgia, myalgia, bilateral flank pains, and frothy urine. His Anti-nuclear antibodies (ANA) and anti-double-stranded DNA (anti-dsDNA) were positive. He also had thrombocytopenia, and acquired coagulopathy. He was started on steroids with good compliance. In 2007 (2 years prior to admission), he was hospitalized for a midbrain cerebrovascular bleed and was discharged with right-sided hemiparesis. Anti-phospholipid antibody syndrome (APAS) was ruled out. Later that year, he was admitted for pleural effusion and was started on anti-Koch’s therapy. In February 2008 (1 year prior to admission), he consented to a kidney biopsy which showed diffuse segmental proliferative and sclerosing lupus nephritis with 18% global sclerosis, 36% segmental sclerosis, and 18% fibrous crescents (Class IV). In July 2008 (5 months prior to admission), he was started on Cyclophosphamide pulse therapy due to persistent heavy proteinuria. Mycophenolate mofetil was added on his 2 nd cycle of cyclophosphamide pulse therapy. After his 3 rd cycle of Cyclophosphamide in September 2008, he developed swelling in his right lower leg with erythema, warmth, and tenderness. The medial side of the leg eventually became hyperpigmented, with erythema, edema, and ulcerations draining purulent discharge. He had fever and chills. For the next 3 months, he was repeatedly admitted and treated as a case of chronic venous insufficiency and cellulitis. He received several antibiotics like Oxacillin, Ciprofloxacin, Vancomycin, Clindamycin and Ampicillin-Sulbactam. Inspite of these drugs, there was minimal improvement. On follow-up in November 2008 (1 month prior to admission), there were new ulcerations noted at the lateral malleolus with satellite lesions at the medial aspect of the right lower leg. He took oral Ciprofloxacin and Clindamycin for a week. However, due to worsening of the wound, he was admitted at the University of the Philippines-Philippine General Hospital (UP-PGH). On admission, the patient had normal vital signs. Pertinent physical exam findings included pale palpebral conjunctivae, edematous right lower leg with a 3 x 2 cm ulcer on the medial side and a 1 x 2 cm ulcer on the right ankle, with yellowish to whitish discharge (Figure 1). Leg edema improved with judicious compressive bandaging and leg elevation. However, due to the persistence of fever, despite negative cultures, antibiotics were empirically shifted to piperacillin-tazobactam. The patient was referred to the Section of Dermatology. Multiple petechiae and purpura on the upper extremities were consistent with cutaneous lupus erythematotus (Figure 2). The multiple raw-based ulcers in the right lower leg draining purulent discharge with well-defined border (Figure 3) showed suppurative and granulomatous infiltrates still consistent with chronic venous insufficiency with secondary bacterial infection. Surgical debridement was done. Multiple draining sinuses in the medial aspect of the right leg were seen. Tissue samples taken yielded Methicillin-resistant Staphylococcus epidermidis (MRSE) sensitive to vancomycin. Despite debridement, the wound continued to drain purulent and bloody discharge, hence, piperacillin- tazobactam was empirically shifted to imipenem and vancomycin. Purulent discharge decreased but with poor CASE RECORDS OF THE DEPARTMENT OF MEDICINE, PGH 2 Center for Natural Sciences and Environmental Research, De la Salle University, Taft Avenue, Manila Case Presentation