Infective Leg Ulcers

1. Vascular

 (a) Venous

 (b) Arterial

 (c) Mixed

2. Neuropathic

 (a) Diabetes

 (b) Tabes

 (c) Syringomyelia

 (d) Spinal injury

 (e) Leprosy

3. Metabolic

 (a) Diabetes

 (b) Gout

4. Hematological

 (a) Sickle cell disease

 (b) Cryoglobulinemia

5. Trauma

 (a) Injury

 (b) Pressure

 (c) Burns

6. Tumors

 (a) Basal cell carcinoma

 (b) Squamous cell carcinoma

 (c) Sarcoma

7. Infection

 (a) Bacterial

 (b) Fungal

 (c) Protozoal

8. Panniculitis

 (a) Necrobiosis lipoidica

 (b) Fat necrosis

9. Pyoderma gangrenosum

10. Autoimmune ulcers

11. Hypertensive ulcers

Several studies have implicated infectious causes for lower-limb ulceration. However, there is no large cumulative experience, and the literature on infectious ulcers is composed of mostly of small series or case reports. Most infectious ulcers are bacterial although viruses, parasites, and fungi have been reported as causative agents mainly in the immunocompromised patients. A list of likely pathogens is included in Table 16.2.

Table 16.2
Infectious causes of limb ulcers



Erysipelas (bullosa)

Streptococcus pyogenes

Fasciitis necroticans

Streptococcus hemolyticus

Ulcerating pyoderma

Staphylococcus aureus

Gas gangrene


Ecthyma gangrenosum


Septic embolism

Meningococcus and others


Bacillus anthracis


Corynebacterium diphtheria


Several microorganisms

Herpes, CMV, Lues maligna

HSV, CMV, Treponema pallidum


Francisella tularensis

Tropical ulcer

Bacteroides, Borrelia vincenti

Maduramycosis (eumycetoma/mycetoma), Exophiala jeanselmei

Nocardia brasiliensis

Chondroblastomycosis, coccidioidomycosis

Several bacteria


Histoplasma capsulatum

Bacillary angiomatosis

Bartonella henselae

Ulcerating cutaneous tuberculosis

Mycobacterium tuberculosis


Entamoeba histolytica


Leishmania donovani complex


Mycobacterium leprae

Taken from Spentzouris and Labropoulos [2]

16.1.1 Mixed Etiology

Most ulcers have more than one etiology. Ulcers of any primary origin such as ischemic, venous, or neurotropic ultimately get infected as well. Though the dominant disease process must be treated first, the superimposed infections require treatment also.

16.1.2 Pyoderma Gangrenosum

This is a misnomer because these ulcers are noninfected and are an important cause of non-healing ulcers of the leg. Ulcers of pyoderma gangrenosum may be associated with inflammatory bowel disease, inflammatory arthropathy, or myeloproliferative disorders [3]. Half of these ulcers are associated with chronic disease and the remainder are idiopathic. Lesions of the lower limb start as painful pustules which progress to necrosis and ulceration. These ulcers may be single or multiple with raised purple serpiginous undermined borders. Besides antibiotics, immunosuppressive therapy forms the mainstay of treatment.

16.1.3 Mycobacteria-Associated Leg Ulcers

Chronic ulceration due to atypical mycobacteria is a rare but important cause of non-healing leg ulcers. The organisms implicated are Mycobacterium ulcerans, Mycobacterium marinum, and Mycobacterium chelonae. The ulcers may start as a subcutaneous nodule and later transform into an undermined ulcer with an areola. The diagnosis is established by polymerase chain reaction-based identification of the organism. Treatment is with oral clarithromycin and topical silver sulfadiazine with hyperthermia [4]. The therapy needs to be continued for several months, and additional antibiotics may be required for secondary bacterial infection.

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May 13, 2017 | Posted by in GENERAL SURGERY | Comments Off on Infective Leg Ulcers

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