title: Large leg ulcers due to autoimmune diseases.
abstract: BACKGROUND
  Large leg ulcers (LLU) may complicate autoimmune diseases. They pose a therapeutic challenge and are often resistant to treatment. To report three cases of autoimmune diseases complicated with LLU.
  
  
  METHODS
  Case 1. A 55-year old woman presented with long-standing painful LLU due to mixed connective tissue disease (MCTD). Biopsy from the ulcer edge showed small vessel vasculitis. IV methylprednisolone (MethP) 1 G/day, prednisolone (PR) 1mg/kg, monthly IV cyclophosphamide (CYC), cyclosporine (CyA) 100mg/day, IVIG 125G, ciprofloxacin+IV Iloprost+enoxaparin+aspirin (AAVAA), hyperbaric oxygen therapy (HO), maggot debridement and autologous skin transplantation were performed and the LLU healed. Case 2. A 45-year old women with MCTD developed multiple LLU's with non-specific inflammation by biopsy. MethP, PR, hydroxychloroquine (HCQ), azathioprine (AZA), CYC, IVIG, AAVAA failed. Treatment for underlying the LLU tibial osteomyelitis and addition of CyA was followed by the LLU healing. Case 3. A 20-year-old man with history of polyarteritis nodosa (PAN) developed painful LLU's due to small vessel vasculitis (biopsy). MethP, PR 1 mg/kg, CYC, CyA 100 mg/d, AAVAA failed. MRSA sepsis and relapse of systemic PAN developed. IV vancomycin, followed by ciprofloxacin, monthly IVIG (150 g/for 5 days) and infliximab (5 mg/kg) were instituted and the LLU's healed.
  
  
  CONCLUSIONS
  LLU are extremely resistant to therapy. Combined use of multiple medications and services are needed for healing of LLU due to autoimmune diseases.
authors.affiliation: B Shine Department of Rheumatology, Rambam Health Care Campus and Rappaport Faculty of Medicine, Technion, Haifa, Israel. a_rozin@rambam.health.gov.il
authors.forename: Alexander P
authors.initials: AP
authors.lastname: Rozin
authors.forename: Dana
authors.initials: D
authors.lastname: Egozi
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Ramon
authors.forename: Kohava
authors.initials: K
authors.lastname: Toledano
authors.forename: Yolanda
authors.initials: Y
authors.lastname: Braun-Moscovici
authors.forename: Doron
authors.initials: D
authors.lastname: Markovits
authors.forename: Daniel
authors.initials: D
authors.lastname: Schapira
authors.forename: Reuven
authors.initials: R
authors.lastname: Bergman
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Melamed
authors.forename: Yehuda
authors.initials: Y
authors.lastname: Ullman
authors.forename: Alexandra
authors.initials: A
authors.lastname: Balbir-Gurman
mesh_terms: D000818:Animals; D000911:Antibodies, Monoclonal / Q000627:therapeutic use; D001327:Autoimmune Diseases / Q000473:pathology*; D001379:Azathioprine / Q000627:therapeutic use; D002939:Ciprofloxacin / Q000627:therapeutic use; D003520:Cyclophosphamide / Q000627:therapeutic use; D016572:Cyclosporine / Q000627:therapeutic use; D005260:Female; D006801:Humans; D006886:Hydroxychloroquine / Q000627:therapeutic use; D006931:Hyperbaric Oxygenation / Q000379:methods; D000069285:Infliximab; D007814:Larva; D007871:Leg Ulcer / Q000188:drug therapy / Q000209:etiology* / Q000473:pathology* / Q000628:therapy; D008297:Male; D008775:Methylprednisolone / Q000627:therapeutic use; D008875:Middle Aged; D011239:Prednisolone / Q000627:therapeutic use; D016038:Skin Transplantation / Q000379:methods; D016896:Treatment Outcome; D014640:Vancomycin / Q000627:therapeutic use; D014657:Vasculitis / Q000150:complications*; D055815:Young Adult
chemical_list: D000911:Antibodies, Monoclonal; D006886:Hydroxychloroquine; D002939:Ciprofloxacin; D014640:Vancomycin; D016572:Cyclosporine; D003520:Cyclophosphamide; D011239:Prednisolone; D000069285:Infliximab; D001379:Azathioprine; D008775:Methylprednisolone