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中华损伤与修复杂志(电子版) ›› 2024, Vol. 19 ›› Issue (04) : 348 -350. doi: 10.3877/cma.j.issn.1673-9450.2024.04.013

病例报告

下肢小动脉硬化性溃疡伴局部癌变的诊治一例
陈孝强1, 唐建兵1, 宣敏1, 周宇明1, 董云青1, 刘艺杰1, 张玉妮1, 程飚1,()   
  1. 1. 510000 广州,中国人民解放军南部战区总医院烧伤整形科
  • 收稿日期:2024-01-17 出版日期:2024-08-01
  • 通信作者: 程飚
  • 基金资助:
    广州市重点研发计划(202103030003)
  • Received:2024-01-17 Published:2024-08-01
引用本文:

陈孝强, 唐建兵, 宣敏, 周宇明, 董云青, 刘艺杰, 张玉妮, 程飚. 下肢小动脉硬化性溃疡伴局部癌变的诊治一例[J]. 中华损伤与修复杂志(电子版), 2024, 19(04): 348-350.

患者女,83岁,慢性病程。因"右足皮肤破溃伴渗液50年余,加重4月余"入院;家属代诉患者于50年前无明显诱因出现右足背部一黄豆大小丘疹伴水泡,并出现破溃和渗液,经换药愈合后反复破溃和渗液,迁延不愈。4个月前右足溃疡加深伴红肿,附着淡黄色分泌物,伤口剧烈疼痛,影响行走,患者家属予以换药,未见好转。2个月前就诊于中国人民解放军南部战区总医院烧伤整形科创面门诊,定期予清创换药处理,伤口仍难以愈合并逐渐扩大,加深。为求进一步诊治,门诊拟以"右足慢性溃疡"收入病房。既往史:高血压病史10余年,规律服用降压药(具体不详),血压控制在正常范围。否认糖尿病、冠心病等其他慢性病史。专科检查:右足背部可见一4 cm×2.5 cm不规则溃疡,深达深筋膜层,高低不平。往踝部延伸可探及一窦道,穿透皮肤形成窦口。基底局部可见黄色脓性分泌物,闻之无异味。创缘呈红紫色,轻度水肿,触之明显疼痛。皮温正常。双足背动脉可触及搏动,双足末端皮温偏低。双下肢未见静脉曲张及皮肤淤青等,无凹陷性水肿(图1)。辅助检查:心电图检查提示:大致正常心电图。胸部正位X线片:1.主动脉粥样硬化;2.心肺膈未见明显异常。下肢X线片示:1.右足背外侧软组织内异常密度影;2.右踝及右足骨关节未见异常(图2)。下肢血管超声检查示:1.双下肢动脉广泛粥样硬化伴斑块形成;2.双下肢深静脉血流通畅。诊断为:右足慢性溃疡;小动脉硬化性溃疡(Martorell溃疡)?鉴别诊断:坏疽性脓皮病:溃疡型的临床特点(起初丘疹、水疱,迅速进展为大片糜烂和溃疡,溃疡边缘呈不规则、紫红色、潜行性扩展,疼痛剧烈)。

图1 入院时创面大体观察
图2 右足正侧位X线检查
图3 切开联合NPWT术后。A示扩创;B示NPWT 7 d后
图4 术后3 d右足溃疡组织病理。A示显著胶原化的纤维结缔组织显急性及慢性炎(HE,×10);B示增生的小血管(蓝色箭头),周围多量淋巴细胞浸润(HE,×40);C示鳞状上皮层钉突样突破基底层(红色虚线)(HE,×20);D示鳞状上皮中-重度异型增生,泡沫核(红色箭头),细胞核深染,核扩大呈毛虫状(黑色箭头)(HE,×40)
图5 右足部溃疡扩大切除术+右大腿取皮+游离皮片移植+NPWT术后溃疡组织病理表现(HE,×20)
图6 创面愈合随访。A示术后7 d创面;B示术后14 d创面;C示术后3个月创面;D示术后1年创面
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