Image - (2016) Volume 4, Issue 1
Department of Dermatology, National University Health System, Singapore
Received date: March 06, 2016 Accepted date: March 08, 2016 Published date: March 12, 2016
Citation: Yong AM, Yang SS. Lower Limb Ulcer: A Variant of Trophic Syndrome. Ann Clin Lab Res. 2016, 4:1.
A 66-year-old man presented to the Stroke Unit with recurrent symptoms of capsular warning syndrome and an acute left corona radiate infarct. Incidentally, he reports a history of 2-month right shin ulceration and admits to frequent manipulation due to altered sensation. Examination revealed a 7 × 5 cm ulcer over the inferomedial surface of his right knee, with an eschar and a sloping edge. There were no vesicles or discharge
A 66-year-old man presented to the Stroke Unit with recurrent symptoms of capsular warning syndrome and an acute left corona radiate infarct. Incidentally, he reports a history of 2-month right shin ulceration and admits to frequent manipulation due to altered sensation. Examination revealed a 7 × 5 cm ulcer over the inferomedial surface of his right knee, with an eschar and a sloping edge. There were no vesicles or discharge (Figure 1).
Figure 1: Ulceration over the right lower limb with a dry necrotic eschar.
Of note, there was no evidence of livedo reticularis or a personal or family history of autoimmune disease; neither did he have no history of renal impairment with normal calcium and phosphate levels. This patient did report an unusual itch sensation on his right knee, and had started scratching his knee repetitively over the past 3 months. This also coincided with recurrent weakness and numbness of his right lower limb, along with symptoms of altered and tingling sensation over the same area.
Management involved patient education and avoidance of selfinjury. Topical treatment included combination Betamethasone 0.025% and Clioquinol 3% cream to eczematous edges. Pharmacological treatment involved Pregabalin 25 mg twice daily for symptomatic relief.
Capsular warning syndrome involves recurrent transient lacunar syndromes that usually precede a capsular infarction. In our patient, the classical triad of TTS including intractable ulceration with anesthesia and paresthesia were present in his right lower limb as neurologic sequelae. Because of the analgesia, repeated manipulation to alleviate these uncomfortable sensations have eventually resulted in persistent ulceration and tissue loss.
Trophic syndrome remains a clinical challenge and one should have a higher index of suspicion of the diagnosis in the setting of chronic ulceration post-stroke [1].
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